2020 flexible benefits enrollment & reference guide 2020 interactive enrollment...goal is to...
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If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage.
Please see the Legal Notices section for details.
2020 Flexible Benefits Enrollment & Reference Guide
This booklet contains all of the information needed to understand your Flexible Benefits for 2020.
Contents • Introduction to Your Benefits ................................................................................................................................. 3
• Benefits Eligibility ................................................................................................................................................... 4
• Changing Your Coverage During the Year ............................................................................................................ 5
• What Happens to Your Coverage if You Leave Lehigh? ....................................................................................... 5
• Your 2020 Medical Options ................................................................................................................................... 6
– The PPO Plans ................................................................................................................................................... 6
– The HDHP .......................................................................................................................................................... 7
– The Keystone HMO ........................................................................................................................................... 7
– Summary of Medical Plan Options .................................................................................................................... 8
– Preventive Care ................................................................................................................................................. 9
– Capital Blue Virtual Care (telehealth) ................................................................................................................ 9
• Prescription Drug Plan ......................................................................................................................................... 10
• Vision Coverage .................................................................................................................................................. 11
• Dental Coverage .................................................................................................................................................. 12
– The Preventive Incentive Program ................................................................................................................... 12
• Tax-Advantaged Accounts .................................................................................................................................. 13
– Health Savings Account (HSA) ........................................................................................................................ 13
– Flexible Spending Accounts (FSAs) ................................................................................................................ 13
• Financial Protection ............................................................................................................................................. 16
– Life Insurance .................................................................................................................................................. 16
– Long-Term Disability Insurance ....................................................................................................................... 17
• Voluntary Benefits ................................................................................................................................................ 18
– Accident Insurance ......................................................................................................................................... 18
– Critical Illness Insurance ................................................................................................................................. 18
• Glossary ............................................................................................................................................................... 19
• Frequently Asked Questions ............................................................................................................................... 21
• Where to Go for Help ........................................................................................................................................... 23
• Legal Notices ....................................................................................................................................................... 24
• Summary of Benefits and Coverage ......................................................................................................Appendix 1
• Plan Design Details ...............................................................................................................................Appendix 2
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Introduction to Your Benefits Lehigh University is committed to providing you and your family with a comprehensive and competitive benefits package. Our goal is to provide high-quality, valuable benefits that are sustainable for both you and the University in the long term.
This Flexible Benefits Enrollment & Reference Guide provides details about the benefits available to you through Lehigh for 2020: • Medical (including Prescription Drug and Vision)• Dental• Spending and savings accounts• Life insurance (for you and your dependents)• Disability• Voluntary accident and critical illness
Consider all your benefit plan choices carefully. Read this guide to find out what’s new for the upcoming year and the important changes we have made. Think about which plans make the most sense for you and your family, and, finally, make any needed changes during Open Enrollment. Be sure to compare each plan’s features and your payroll contributions, and consider which plan best fits your needs.
Open Enrollment is your once-a-year chance to make changes to your benefits. During Open Enrollment you can: • Change plans • Add or delete dependents from your coverage • Change coverage levels • Enroll in a Health Care or Dependent Care Flexible Spending Account (FSA)• Elect to contribute to the Health Savings Account (HSA) if you enroll in the High Deductible Health Plan (HDHP) option for
2020.
The benefit elections you make during Open Enrollment are effective from January 1, 2020 through December 31, 2020.
After Open Enrollment ends, you will not be able to make benefit changes until next year’s Open Enrollment unless you experience a Qualifying Life Event (QLE) (e.g., you get married or become a parent).
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Benefits EligibilityYou are eligible for benefits if you are a full-time (or work at least 75% of a full work schedule), salaried member of Lehigh’s faculty or staff employed in a benefits-eligible position. You can also enroll your eligible dependents, including your:• Spouse/partner*• Child(ren) up to the end of the month in which they become age 26• Disabled child(ren) without age limitation (coverage, and its continuation, is subject to
required certification with the carrier)
All benefits included in the Flexible Benefits Plan — flexible spending accounts and medical, dental, life, dependent life, and long-term disability insurances — are available to new staff members on the first of the month following their first work day. For new faculty members, benefits are available beginning on their first work day. However, their coverage does not begin until enrollment selections are completed online in Lehigh Benefits.
*If you choose to have your spouse or partner covered by Lehigh’s medical insurance plan, you will be charged a $100/month surcharge until you complete a Spousal Surcharge Waiver request and HR approves it. Learn more about eligibility and submitting your election on the Lehigh Benefits website or by calling the Lehigh Benefits Service Center at 1-844-342-4002.
Don’t Miss Your Chance to Enroll!
• If you are a current employee: Enrollment for 2020 benefits will be November 4 - 18, 2019 for coverage effective January 1, 2020. – If you do nothing during open enrollment, your current elections will continue in 2020 with the exception of flexible spending accounts and employee HSA contributions, which must be renewed annually.
• If you are a new hire: New employees (both faculty and staff members) must enroll within 30 days of your first day of work.– Coverage for faculty members is effective
as of their first day of work provided they complete their enrollment in Lehigh Benefits within the first thirty days of employment.
– Coverage for staff members is effective on the first of the month following your start date, provided completed enrollment materials are received within 30 days of your first work day.
– If you miss your enrollment period deadline, you will be assigned Lehigh’s default benefit coverage of PPO individual coverage at a monthly cost of $235. No dependents will be enrolled in medical coverage; nor will dental insurance, supplemental or dependent life insurance, or FSAs be available to you or any dependents.
Keep in mind you will not be able to make a change to your benefits during the year unless you experience a Qualifying Life Event (QLE).
Enrollment Is Easy Enroll on the Web
• Log in to “Connect Lehigh” from the upper left corner of the Inside Lehigh homepage
• Select the “Employee” tab• Select “Lehigh Benefits” from the list of applications.• Review your “To Do” list.• Select the button under the words “Enroll Now!” that is
labeled “Click Here To View Your Benefits.” NOTE: As annual notices are updated, you may need to review your To Do list prior to proceeding with enrollment or benefits changes. Or Use The App
• Download the Benefitfocus app from The App Store or the Google Play Store
• Log in by using the ID “lehighbenefits” on the initial screen, then sign in with your Lehigh ID and password.
Whether you use the web or the app, you’ll be asked to confirm your dependents and answer a few questions before you begin enrollment. You can review your current elections, use the comparison shopping tool to view estimated out of pocket costs for you in each plan, change your elections, update your beneficiary information and more.
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What Happens to Your Coverage if You Leave Lehigh?Your coverage does not end right away if you separate from the University. The Consolidated Omnibus Budget Reconciliation Act’s (COBRA) continuation coverage provides you the option of continuing your medical and/or dental plan for up to 18 months. You would be responsible for paying the entire premium amount to Lehigh’s COBRA administrator plus a 2% administrative fee.
The provisions of COBRA also apply to dependents that lose coverage, including a child who turns 26. For medical and dental coverage, it is your responsibility to notify Lehigh Benefits when your child reaches age 26 or you may jeopardize your dependent’s access to COBRA coverage.
Additional information is available through the Lehigh Benefits website or by calling 1-844-342-4002.
Changing Your Coverage During the YearThe benefit elections you make during Open Enrollment take effect on the following January 1.Your elections remain in effect until the next Open Enrollment period, unless you experience a Qualifying Life Event (QLE), such as getting married or divorced or having or adopting a baby. You can add or drop dependents from your coverage as the result of a QLE, however you cannot change your medical plan election (e.g., you can add a new spouse to your medical coverage, but you can’t change from the PPO to the HDHP as a result of getting married).
It is your responsibility to notify Lehigh Benefits within 31 days of a QLE and request appropriate flexible benefit changes when you experience:• Change in marital/partnership status such as marriage/registration or
divorce/dissolution• Addition or change in number of dependents through birth/adoption of
child or change in child dependent’s status (such as reaching age 26)• Death of a dependent child or spouse/partner• Changes related to employment or location including change in
employment, retirement, significant change in residence location orreduction in work hours below the Affordable Care Act’s employer planeligibility threshold; or, eligibility for healthcare marketplace
If you fail to submit a QLE change request within 31 days, we will retroactively cancel coverage in the case of a dependent whose benefit eligibility ends. However, we cannot refund premiums paid for coverage that was not available. In other words, paying for coverage that your dependent is not entitled to receive will not create that entitlement. It simply means that you are paying more for coverage than you need to. Furthermore, you may jeopardize your dependent’s access to COBRA coverage by failing to notify Lehigh Benefits in a timely fashion.See the list at right for more information on required documents and key dates. Learn more about QLEs by visiting the Lehigh Benefits website or calling the Lehigh Benefits Service Center at 1-844-342-4002.
DOCUMENTATION AND DATES FOR QUALIFYING
LIFE EVENTS
AdoptionEvent Date: Date adoption is finalizedDocumentation: Finalized adoption decree
BirthEvent Date: Baby’s birth dateDocumentation: Birth Certificate
DivorceEvent Date: Date the divorce is finalizedDocumentation: Finalized divorce decree
Eligible for Other CoverageEvent Date: Date new coverage becomes effectiveDocumentation: Benefits confirmation statement showing who is covererd and date of new coverage
Loss of Coverage by DependentEvent Date: First day you and or/dependents no longer have coverageDocumentation: Benefits confirmation statement showing who was covered and date of termination of coverage
MarriageEvent Date: Date of MarriageDocumentation: Marriage certificate
Annual Open Enrollment for Spouse/PartnerEvent Date: Date new coverage becomes effective Documentation: Benefits confirmation statement showing who is covered and start date of new coverage
Spouse/Partner Gained Coverage Due to Employment Status ChangeEvent Date: Date new coverage becomes effective Documentation: Benefits confirmation statement showing who is covered and start date of new coverage
Spouse/Partner Loses Coverage Due to Employment Status ChangeEvent Date: First day you and/or dependents no longer have coverageDocumentation: Benefits confirmation statement showing who was covered and termination date of the coverage5
Your four medical insurance options include: Capital Blue Cross Preferred Provider Organization (PPO) plans:
– PPO– PPO-Plus– Capital Blue Cross High Deductible Health Plan (HDHP)
Keystone Health Maintenance Organization (HMO)
When you enroll in a medical plan through the University, you are automatically enrolled in Prescription Drug coverage through Express Scripts and Vision coverage with Davis Vision.
The PPO PlansWith the PPO or PPO Plus plans, you have a choice each time you need care — you may choose health care providers within the plan’s network or visit any provider outside the network. However, you’ll typically pay more for care when you use out-of-network providers. That’s because Capital Blue Cross negotiates discounted fees for covered services with providers in their network, which allows us to set the in-network annual deductible at a lower level than the annual deductible for out-of-network care.
If you choose a PPO plan, you will pay more in premium contributions, but less when you receive care.
IN-NETWORK PREVENTIVE CARE Preventive care is 100% covered in all health care plans when received from in-network providers. Preventive care includes services such as physical examinations and certain immunizations.
Preventive services are divided into three groups:• Adults• Women• Children
Go to the Preventive Care section for details.
Your 2020 Medical OptionsLehigh offers four medical plans through Capital Blue Cross. While all of the options cover the same services and treatments, and cover preventive care in full when received from in-network providers, they differ in how much you pay in payroll contributions and what you pay when you receive care. To make an informed decision about which option is right for you and your family, evaluate your health care needs and review how you pay for services under each option.
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Although they cover the same services, there are some key differences between the HDHP and the PPOs:
HDHP PPO
• Lower payroll deductions• Pay more out-of-pocket when
receiving care• Higher annual deductible• Lehigh contribution to the HSA
• Higher payroll deductions• Pay less out-of-pocket when
receiving care• Lower annual deductible • No HSA
Find more information about this plan by reading the HDHP User’s Guide available on Lehigh Benefits.
WHO SHOULD ENROLL IN THE HDHP? Do you expect your usage to be moderate to low (only wellness visits and occasional illness)? If so, consider the plan with the higher deductible. You could save money by paying less from your paycheck for your coverage. If you are concerned about the risk of unexpected expenses, consider purchasing voluntary accident or critical illness insurance.
The HDHPThe HDHP gives you more control over how you spend — or save — your health care dollars. If you enroll in the HDHP, you can contribute to a tax-advantaged Health Savings Account (HSA) that includes a contribution from Lehigh. You can also choose to contribute up to annual IRS limits. Use this account to help pay for eligible health care expenses today, or to save for future medical, dental, and vision expenses. See the Health Savings Account section for more information.
Like the PPO plan, you have the freedom to see both in-network and out-of-network providers, but you’ll typically pay more for services from out-of-network providers and you’ll have to satisfy a separate, higher out-of-network deductible. Additionally, the HDHP network is the same network that is available in the PPO and PPO Plus plans.
The HDHP has a higher annual deductible than the PPO plans, but you’ll pay less in payroll contributions. It’s important to note that the full family deductible must be satisfied before the plan pays benefits for anyone covered in the plan. If you cover any dependents, you must meet the entire family deductible before the plan begins reimbursing your medical or prescription drug expenses. One family member, or all family members combined, can satisfy the deductible.
The Keystone HMOThe HMO provides the maximum level of coverage with lower premiums and the lowest out-of-pocket costs. In addition, you will not be responsible for first satisfying an annual deductible before the plan pays benefits. In return, you’ll be required to receive care from in-network providers, manage your care through a Primary Care Physician (PCP) and receive referrals from your PCP if you would like to receive care from a specialist. Care received from out-of-network providers will not be covered, other than in an emergency, as determined by Capital Blue Cross. This may be the most cost-effective option for employees living in the 21 county area surrounding the University who are comfortable with using only in-network providers.
2020 Monthly Medical Premiums
PLAN Individual Employee +Spouse/Partner
Employee+Child
Employee+Family
University Contribution (All Plans) $554 $1,144 $1,040 $1,649
HDHP $35 $133 $113 $196PPO $235 $581 $517 $843PPO Plus $318 $766 $684 $1,111Keystone Health Plan (HMO) $113 $318 $279 $460
HEALTH ADVOCATE BENEFITThe Health Advocate benefit offers access to a personal advocate and clinical resources to help resolve a wide range of issues, including but not limited to:
• Assistance with eldercare and Medicare issues
• Finding Doctors• Healthcare coaching• Obtaining second opinions• Resolving claim disputes• Navigating insurance plans• Researching treatments• Scheduling appointments• Uncovering bill mistakes
To contact Health Advocate by phone, call 1-866-695-8622.
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Summary of Medical Plan OptionsThe table below provides a summary comparison for key benefits across the medical plan options available for 2020. See the Summary of Benefits and Coverage and Plan Design Details sections of this guide for more information about each plan and covered preventive services.
PPO PPO Plus HDHP Keystone HMO***
Network National National National 21 County/Lehigh Valley
In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network
Annual Deductible
Individual $200 $500 $0 $500 $1,400 $2,500 $0
Family $600 $500 /person $0 $500 /person $2,800* $5,000* $0
Coinsurance 20% 30% 10% 20% 20% 30% N/A
Out-of-Pocket Maximum for all medical and prescription drug charges
Individual $4,000 No limit $4,000 No limit $6,900 No limit $4,000
Family $8,000 No limit $8,000 No limit $13,800 No limit $8,000
Physician Services
Office Visit $25 copay/visit 30% coinsurance $25 copay/visit 20% coinsurance 20% coinsurance 30% coinsurance $25 copay/visit
Specialist Visit $40 copay/visit 30% coinsurance $40 copay/visit 20% coinsurance 20% coinsurance 30% coinsurance $40 copay/visit
Preventive Care (Administered in accordance with Preventive Health Guidelines & PA state mandates)
No charge Mandated screenings and immunizations: 30% coinsurance; Routine physical exams: Not covered
No charge Mandated screenings and immunizations: 20% coinsurance; Routine physical exams: Not covered
No charge Mandated screenings and immunizations: 30% coinsurance; Routine physical exams: Not covered
No charge
Hospital Services
Inpatient Coverage
20% coinsurance 30% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance $200/admission
Outpatient Hospital
20% coinsurance 30% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance No charge
Emergency Room
$100 copay/service, waived if admitted $100 copay/visit, waived if admitted 20% coinsurance $100 copay/visit, waived if admitted
Urgent Care $40 copay/service 30% coinsurance $40 copay/service 20% coinsurance 20% coinsurance 30% coinsurance $40 copay/ service
Maternity Services
Prenatal/Postpartum Care
20% coinsurance 30% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance No charge
Hospital 20% coinsurance 30% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance No charge
Mental Health **
Inpatient 20% coinsurance 30% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance No charge
Outpatient $25 copay/visit 30% coinsurance $25 copay/visit 20% coinsurance 20% coinsurance 30% coinsurance $25 copay/visit
Substance Abuse **
Inpatient 20% coinsurance 30% coinsurance No charge 20% coinsurance 20% coinsurance 30% coinsurance No charge
Outpatient $25 copay/visit 30% coinsurance $25 copay/visit 20% coinsurance 20% coinsurance 30% coinsurance $25 copay/visit
Prescription Drugs
Generic 10% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
10% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
10% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
10% coinsurance
Brand Forumulary 20% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
20% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
20% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
20% coinsurance
Brand Non-Forumulary 30% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
30% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
30% coinsurance
Coinsurance plus amount over Express Scripts allowable amount
30% coinsurance
*For all coverage levels other than employee only, the entire family deductible must be met before the HDHP plan starts paying medical and pharmacy benefits to anyone in the plan. Medical and pharmacy expenses count toward the deductible.**Depending on which medical plan you choose, Mental Health and Substance Abuse benefits are provided through either Magellan Health Services or Integrated Behavioral Health. Preauthorization is required in all plans. Failure to preauthorize with KHP results in no benefit.***Care from out-of-network providers is not covered, other than in an emergency, as determined by Capital Blue Cross.See the Summary of Benefits and Coverage and Plan Design Details sections of the 2020 Enrollment and Reference Guide to learn more about specific coverages and limits as well as preauthorization information.
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Preventive CarePreventive care is any covered medical service or supply that is received in the absence of symptoms or a diagnosed medical condition. Preventive care includes preventive services such as physical examinations, certain immunizations, and screening tests.
Federal laws covering medical, dental and/or vision preventive care change often. Check to see what’s covered at https://www.healthcare.gov/preventive-care-benefits.
HOW TO CHOOSE YOUR MEDICAL PLANUsing the comparison tools on Lehigh Benefits will help you find the plan that’s best for you.
Lehigh Benefits offers a powerful financial modeling tool to project the total cost of your medical coverage elections using:• the average claims experience of Lehigh employees, if you have not participated in the plan in the past,• your own claims experience if you’ve been covered by a Lehigh plan in prior years,• the national average claims experience for persons with similar age, gender, and regional demographics as you
and your dependents, and• customized modeling of your projected medical claims for next year.
Take the time to review plan features — such as an HSA with a contribution from Lehigh — and not just what you contribute from your paycheck. Consider your needs and preferences:1. How much coverage do I need?
• See how the services you’ll likely need in 2020 are covered under each medical plan • Do you need supplemental coverage?
2. What will be my total cost? • Out of your paycheck: Your contributions for coverage • Out of your pocket: What you pay when you receive care
– Copays– Deductibles– Coinsurance
3. How do I prefer to pay? • Pay more from my paycheck, and less when I need care (lower deductible plans) • Pay less from my paycheck, and more when I need care (higher deductible plans)
– Consider your ability to cover large/unexpected medical bills4. Do I want an HSA?
• Only available to employees in the HDHP • Lehigh contributes to your HSA (in 2020, $600 individual/$1,200 family) • You can also contribute through pre-tax payroll deductions • Money carries over year to year — build tax-free savings to pay for eligible health expenses, now or in the future
– Additional restrictions apply
Capital Blue Cross Virtual CareCapital Blue Cross Virtual Care (formerly Amwell telehealth) gives covered employees access to board-certified physicians via video consultation on your smartphone, tablet or computer. The Virtual Care app is available in the Google Play and App Stores.You can use Virtual Care if you have a health problem and need urgent care; if you’re not sure you need emergency care; or if you’re simply traveling and need a doctor’s advice. Doctors can diagnose, recommend treatment and even write short-term prescriptions for most non-emergency medical issues. This benefit is included in all medical plans offered by the University. The copay is $10 for HMO and PPO subscribers, and $59 for HDHP subscribers. Visit www.capbluecross.com/virtualcare or the app to find approved providers or to contact patient support.
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Prescription Drug PlanAll of Lehigh’s medical plans include prescription drug benefits through Express Scripts. You can fill your prescriptions at retail pharmacies or through the Express Scripts Home Delivery program. While you have the option to choose which delivery option fits into your lifestyle, you will save time and may save money by having your medication delivered by mail.
Using generic drugs, which cost less than brand-name drugs, can save you money. A generic drug is a drug that contains the same active ingredients as the brand name drug, but can only be produced after the brand-name drug’s patent has expired. With the introduction of our three-tiered plan, it’s important to check with your doctor and pharmacy to see if any of your current medications are non-formulary and subject to higher charges.
FILLING YOUR PRESCRIPTIONS BY MAIL ORDER COULD SAVE YOU MONEYYou are not required to select mail order, but it may be the best, most economical choice:• FREE shipping right to your door• 25% average savings over retail• 90-day supply, so you won’t worry
about running out• 24/7 access to a pharmacist from
the privacy of your home• Automatic refills every three months
Retail Mail OrderGeneric 10% ($25 maximum) per 30-day
supply10% ($75 maximum) per 90-day supply
Formulary Brand Name 20% ($50 maximum) per 30-day supply
20% ($150 maximum) per 90-day supply
Non-Formulary Brand Name 30% ($100 maximum) per 30-day supply
30% ($300 maximum) per 90-day supply
For definition of “formulary” and “non-formulary,” consult the glossary on page 19. If you have questions about whether your prescriptions are considered formulary or non-formulary, contact Express Scripts at 1-866-383-7420 or www.express-scripts.com.
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Vision CoverageVision coverage through Davis Vision is also included in your medical plan coverage. The vision plan provides a benefit for an exam and lenses and frames on a yearly basis. You have the freedom to see any vision provider you choose, but the plan generally covers services at a higher level when you receive care from doctors who participate in the Davis Vision network. If you decide to go to an out-of-network provider, you’ll be reimbursed for exams and eyewear according to the schedule of benefits detailed below.
Davis Vision Program
Service/Product Your In-Network CostOut-of-Network
Reimbursement to YouEye Exam $0 $32Eyeglass Lenses
Standard Single Vision $0 $25Bifocal $0 $36Trifocal $0 $46Post Cataract $0 up to $72Non-standard (i.e., no linebifocals, tints, coatings) Fixed Costs No Additional Benefit
Frames $0 for Davis fashion selection frames. Amount over $110 for non-Davis frames at Visionworks,
less 20% discount on overage; amount over $60 at other providers.
$30
Contact Lenses
Prescription Evaluation and Fitting $0 Daily Wear: $20
Extended Wear: $30Contact Lenses Amount over $75, less 15% discount on
overageSpecialty: $48
Disposable: $75Medically Necessary Contact Lenses (w/prior approval) $0 up to $225
To find a provider who participates in the Davis Vision network, call 1-800-999-5431 or go to www.davisvision.com and follow prompts for general access or member access, as appropriate. The Lehigh University client control code for general access is 4100.
Prior to initial enrollment, call 1-877-923-2847.
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Dental CoverageDental coverage is available even if you waive medical coverage through Lehigh. Unlike medical, where the University pays the majority of your cost for coverage (i.e., the monthly premium), Lehigh does not contribute toward the cost of your dental coverage. You pay the full cost for the coverage, however your contributions are based on attractive group coverage rates.
You have the flexibility to receive care from any dentist you choose, but you will pay less when you visit a dentist who participates in the United Concordia dental provider network. This is because network providers cannot charge more than the Maximum Allowable Charge (MAC). This restriction does not apply to out-of-network providers. When you re-ceive care from an out-of-network provider, you are responsible for any charges in excess of the MAC.
Visit United Concordia’s website at www.ucci.com or call 1-800-332-0366 to find a participating provider.
The Preventive IncentivePreventive care is important for your teeth, too. Cleanings and regular exams for each covered individual are covered at 100% and do not count against the $1,000 annual maximum benefit limit. United Concordia’s plan annually includes:• Two cleanings (six months apart)• Two exams• One set of x-rays
United Concordia Dental Benefit Summary(Maximum annual benefit of $1,000 per person)
Diagnostic & Preventive Service Benefits — Paid at 100% (Does not count toward maximum annual benefit)Semi-annual cleaning, polishing, and examinationAnnual bitewing X-raysComplete X-ray series (every five years)Fluoride treatment (under age 19)Sealant: Under age 16. One sealant per permanent first and second molars in three years.Emergency treatment: Palliative (to alleviate pain), not restorativeBasic Service Benefits — Paid at 80% of MAC*Inpatient consultationAnesthetics: Novocain, IV sedation, generalBasic restoration: Amalgam and composite fillingsNon-surgical periodonticsEndodonticsOral surgerySimple extractionRepair of crowns, inlays, onlays, bridges, and denturesMajor Service Benefits — Paid at 50% of MAC*Surgical periodonticsInlays, onlays, crownsProsthetics: Dentures and bridges; no implantsOrthodontia (under age 19) — Paid at 50% of MAC*Orthodontia lifetime benefit maximum of $1,000 per person*MAC: Maximum Allowable Charge — The negotiated charge the plan pays to providers.
2020 MONTHLY DENTAL PREMIUMS
Employee Only $35.26Employee + One $70.52Employee + Two or More $91.18
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Tax-Advantaged AccountsHealth Savings Account (HSA)The HSA is a tax-advantaged savings account you can use to help cover the costs of your health care when you enroll in the High Deductible Health Plan (HDHP). Lehigh’s HSA administrator is HealthEquity. Here are some important things to know about the HSA: • Money from Lehigh. Lehigh will contribute up to $600 per year to your HSA when you enroll in employee only coverage, and up to $1,200 per year to your account for any other level of coverage. Note, this contribution will be made per pay period and will be prorated based on the date your coverage begins. You must open an HSA in order to receive the Lehigh contribution. • Works like a bank account. Use the money to pay for eligible health care expenses — use your HSA debit card to pay when you receive care or reimburse yourself for payments you’ve made (up to the available balance in the account). • You can save. You decide how much to save and can change that amount at any time. Contribute up to the 2020 annual IRS limit of $3,550 for individuals or $7,100 for family coverage (these amounts include Lehigh’s contribution); $1,000 additional contribution allowed for employees age 55+. • Never pay taxes. Contributions are made from your paycheck on a before-tax basis, and the money will never be taxed when used for eligible expenses. • It’s your money. Unused money can be carried over each year and invested for the future — you can even take it with you if you leave your job. This includes the contribution from Lehigh. • Can be paired with a Limited Purpose Flexible Spending Account (LPFSA). You can use your HSA for eligible medical, dental and vision expenses. You can use your LPFSA for tax savings on eligible dental and vision expenses. • Important restrictions apply when you become Medicare/Social Security eligible. Once you are enrolled in any part of Medicare, you will not be eligible to contribute to an HSA. If you are receiving Social Security payments prior to age 65 you will be enrolled in Medicare automatically when you turn 65 and will become ineligible to contribute to an HSA. Taxes and penalties will be applied by the IRS if you continue contributing. Download this information sheet from Health Equity for more information. (https://hr.lehigh.edu/sites/hr.lehigh.edu/files/medicare.pdf)For more information about the HSA, including how to set up an account and rules and restrictions, contact HealthEquity at 1-866-346-5800 or www.healthequity.com or visit the resource center at learn.healthequity.com/lehighuniversity/hsa.
Flexible Spending Accounts (FSAs)Flexible Spending Accounts (FSAs) let you set aside money from your paycheck — before federal income taxes — to pay for certain out-of-pocket health care and/or dependent care expenses, reducing your taxable income. Consider enrolling in one to help pay for your expenses. The type of FSA in which you can participate is based on your medical plan election.
If you elect either PPO or the HMO, or you waive Lehigh medical coverage, you can participate in either or both of the following:• Health Care FSA• Dependent Care FSA
If you elect the HDHP, you can participate in either or both of the following:• Limited Purpose Health Care FSA (covers dental and vision claims)• Dependent Care FSA
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Health Care FSA • You can use the money in your Health Care FSA to reimburse yourself
for eligible expenses, including medical, prescription, dental, hearing, and vision care expenses that exceed or are not covered by your medical plan.
• When you enroll, you can elect to contribute up to $2,700 annually. • Plan carefully when deciding how much to contribute to your FSA.
You can carry over only $500 of any unclaimed balance in a Health Care FSA into the new year.
• Note: You cannot contribute to the Health Care FSA if you enroll in the HDHP.
Limited Purpose FSA (LPFSA)• You can use the money in your LPFSA to reimburse yourself for
eligible dental and vision care expenses that are not paid by your dental or vision plan.
• When you enroll, you can elect to contribute up to $2,700 annually. • Plan carefully when deciding how much to contribute to your FSA.
You can carry over only $500 of any unclaimed balance in a LPFSA into the new year.
• Note: You can only contribute to the LPFSA if you enroll in the HDHP.
Dependent Care FSA• You can use the money in your Dependent Care FSA to reimburse
yourself for eligible child care expenses for dependents under age 13 when it is necessary for you and/or your spouse to work or attend school full-time;
• Or you can use the money in your account for expenses for other eligible dependents (including your spouse) who are incapable of caring for themselves, depend on you for more than half of their support, and live with you for more than half of the year.
• When you enroll, you can elect to contribute up to:– $2,500 annually if you are married and file separate income tax
returns– $5,000 annually, combined between you and your spouse, if your
spouse has an account through another employer• Money in your account does not roll over year to year, so plan
carefully. If you don’t use it, you’ll lose it.
Additional information is available through the Lehigh Benefits website or by calling 1-844-342-4002.
Wageworks Healthcare FSA Debit CardLehigh’s FSAs are administered by Wageworks, which offers a debit card for convenient direct payments from your FSA account at the point of sale when you receive qualified services.
Please note that any claims from the prior year (2019) that you need to pay after December 31, 2019 must be paid via a claims submission on the Wageworks website. Your debit card will turn over to the 2020 claims year and cannot be used to pay for 2019 expenses beginning January 1, 2020.
QUALIFIED MEDICAL EXPENSES FOR FSA USEYou can use your Health Care FSA for expenses that would generally qualify as medical, dental and vision expenses, including, but not limited to:• Deductibles• Office visits• Prescription drugs• Hospital stays• Lab work or x-rays• Eyeglasses or contact lenses• Hearing aids• Dental work• Crutches, braces or wheelchairs
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Account Feature HSA Limited Purpose FSA Health Care FSA Dependent Care FSA
Available if you enroll in the…
HDHP HDHP • PPO• PPO Plus• Keystone HMO
You can also contribute to the Health Care FSA if you waive medical coverage through Lehigh, provided neither you nor your spouse is enrolled in a high deductible health plan elsewhere
All medical plans, or no coverage (you do not need to be enrolled in a medical plan through Lehigh to enroll in the Dependent Care FSA)
Maximum annual contribution (including Lehigh contribution)
• $3,550 Employee only• $7,100 all other
coverage levels• $1,000 additional
contribution allowed for employees age 55+
Note: Lehigh contributes up to $600 for employee only coverage and $1,200 for all other levels of coverage
$2,700 $2,700 $5,000 (combined employee/spouse amount)
Eligible expenses Qualified health care expenses (including medical, prescriptiondrug, dental and vision)
Qualified dental and vision expenses only
Qualified health care expenses (including medical, prescription drug, dental and vision)
Qualified expenses for dependents (not to be used for health care expenses for dependents)
Earns interest tax free Yes Not applicable Not applicable Not applicable
Carryover of unused funds to the next year
Yes Up to $500 Up to $500 No
Portability if you leave Lehigh
Yes No No No
Access to contributions
Current account balance only
Entire amount elected for the year
Entire amount elected for the year
Current account balance only
Compare the HSA and FSAs
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Financial ProtectionLife and disability insurance can provide important financial protection as well as peace of mind for you and your family by replacing income or covering medical expenses in the case of injury or death. Selecting the right level of coverage to ensure adequate protection begins with you.
Life Insurance Basic Life InsuranceAs part of Lehigh’s benefits program, you automatically receive Basic Life Insurance benefits equal to one times your salary at no cost to you. For purposes of life insurance, your salary is your base salary as budgeted at the start of the plan year (i.e., January 1) or your hire date if you’re a new employee.
Age (as of January 1) Monthly Premium for $1,000 of Coverage16 to 29 $0.038 30 to 34 $0.044 35 to 39 $0.071 40 to 44 $0.110 45 to 49 $0.165 50 to 54 $0.231 55 to 59 $0.352 60 to 64 $0.638 65 to 69 $1.100 Over 70 $1.837
PROOF OF INSURABILITYNew employees can elect up to the maximum amount without submitting evidence of insurability for themselves and their dependents.
For all future enrollments, however, employees are required to provide evidence of insurability for increasing coverage by more than one times salary during any plan year.
• For your dependents: You can buy life insurance for your spouse/partner, your child(ren), or both. Dependent life insurance can cover a child from 15 days of age up to the end of the month in which he or she becomes age 26. You are the beneficiary for any dependent life insurance you select. Important note regarding duplication of coverage: If your spouse is also a benefits-eligible Lehigh employee you can not carry spousal life insurance for them. Also, only one of you may carry life insurance for your children. Paying for duplication of coverage does not mean the insurance company will pay more than one claim.
Dependent Life PremiumsCoverage Options Monthly Premium Dependent Life Insurance Amount
Spouse/Partner$2.20 $10,000$4.40 $20,000$6.60 $30,000
Child(ren)$0.40 $5,000$0.80 $10,000
Under current law, premiums for dependent life insurance cannot be paid with tax-free dollars. The cost of the dependent life insurance option you choose will be paid through salary deduction on an after-tax basis.
Supplemental Life Insurance You have the option to purchase Supplemental Life Insurance for you and your dependents
• For you: You can purchase supplemental coverage in increments of one to four times your salary. The combined maximum total coverage available for Basic Life Insurance and Supplemental Life Insurance is five times your base salary, up to a limit of $1,500,000. The cost of the supplemental coverage is based on your age:
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Important Tax Note for Life InsuranceBecause the cost of life insurance is paid with pre-tax dollars, some taxable income will result from the value of coverage over $50,000. There are no tax consequences for coverage of $50,000 or less. If your coverage exceeds $50,000, the Internal Revenue Service (IRS) requires the University to include the taxable value of the premium that purchases life insurance in excess of $50,000 on your W-2 form. The IRS defines the taxable value, and this value may be different from the actual premium paid. The difference in the amount of extra taxable income is generally minimal unless you are crossing an age bracket during the plan year.
Lehigh determines the age-based premium using your age on January 1; the IRS uses your age on December 31. In addition, you’ll pay FICA (Social Security and Medicare) taxes on that amount as well if your pay is less than the Social Security wage base maximum.
HOW MUCH LIFE INSURANCE DO YOU NEED?In evaluating your life insurance needs, it is important to look at the present and plan for the future to make informed decisions. Here are some key questions to consider when evaluating life insurance:• What are your financial commitments and
for what expenses would your family be responsible if you should die?
• What other resources are available to those who are financially dependent on you?
• What standard of living do you want your dependents to have without you?
• How much life insurance do you already have?
Long-term Disability InsuranceLehigh’s Short-term Disability (STD) plan, as defined in the Faculty and Staff Guides, provides coverage for the first 26 weeks (six months) of disability. Once you have exhausted your STD benefit, Lehigh’s Long-term Disability (LTD) plan continues to replace a portion of your earnings — 66 2/3% of your LTD Base Salary — if, after 26 weeks, you are still unable to work for an extended period of time due to an illness or injury. The University pays the full cost of this coverage.• For the period January 1 through June 30, your LTD Base Salary is your base salary as of January 1. • For the period July 1 through December 31, your LTD Base Salary is your base salary as budgeted for the new fiscal year.
Selecting Pre- or Post- Tax Premium PaymentsYou decide if you want the premium for your LTD coverage paid pre- or post-tax. The choice you make affects how your benefit is taxed when paid. • Purchasing LTD coverage on a “pre-tax” basis means paying federal income tax on the benefit if you become disabled
but paying no federal income tax on the premium.• Purchasing LTD coverage on a “post-tax” basis means paying federal income tax on the premium but paying no
federal income tax on the benefit if you become disabled.
To qualify for LTD benefits, you will generally need to be totally disabled and, as a result, unable to work for 180 continuous days. The insurance company, not Lehigh, determines whether you are disabled and eligible for LTD. Once benefit payments begin, they can continue for as long as you are totally disabled and until you reach your Normal Retirement Age (as defined by your access to full Social Security income benefits) or longer if your disability begins after age 60.
Other sources of disability income are taken into consideration to determine the benefit provided. Disability benefits received from any state disability plan, Social Security, and the LTD portion of the disability plan, combined, won’t exceed 66 2/3% of your benefits eligible pay.
Additional information is available through the Lehigh Benefits website or by calling Human Resources at 610-758-3900.
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Voluntary Benefits – Accident and Critical Illness In addition to your primary medical plan, you may want to consider voluntary Accident and/or Critical Illness coverage through Aflac. These plans are intended to supplement your primary medical plan. These are not standalone medical plans. They provide additional coverage to help pay expenses your medical plan may not cover. These plans do not provide the level of medical insurance coverage you need in order to meet health care reform requirements. You pay the full cost of coverage through post-tax payroll deductions, which means your benefit, when paid, is tax free.
About Accident InsuranceYou can’t always avoid accidents — but you can help protect yourself from accident-related costs that can strain your budget. Accident insurance supplements your medical plan by providing cash benefits in cases of accidental injuries. You can use this money to help pay for medical expenses not covered by your medical plan, such as your deductible or coinsurance, or for ongoing living expenses, such as your mortgage or rent.
You have two benefit coverage options: Low or High.
Benefits are paid:• Directly to you, unless assigned to someone else.• In addition to any other coverage, such as through your
medical plan.• Tax free, because you pay for each of these benefits
with after-tax money.• The policy pays you a benefit up to a specific amount for:
– Dislocation or fracture– Initial hospital confinement– Intensive care– Ambulance– Medical expenses– Outpatient physician’s treatment
The actual benefit amounts depend on the type of injuries you have and the medical services you need.
About Critical Illness InsuranceWhen a serious illness strikes, critical illness insurance can provide financial support to help you through a difficult time. It protects against the financial impact of certain illnesses, such as a heart attack or cancer. You receive a lump-sum benefit to cover out-of-pocket expenses for your treatment that are not covered by your medical plan. You can also use the money to take care of your everyday living expenses like housekeeping services, special transportation services and day care.
You have two benefit coverage options: $10,000 or $20,000.
Benefits are paid directly to you, unless assigned to someone else.
Important note regarding duplication of coverage: If you are taking family coverage and both parents are Lehigh employees, only one should cover the family. Duplication of coverage does not guarantee duplication of benefit payment.
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Glossary Annual DeductibleThe amount you pay each year out of your own pocket before your medical plan covers a portion of the cost for covered expenses through coinsurance. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. Note that if you enroll in any coverage level other than “employee only” for the High Deductible Health Plan (HDHP), you will need to meet the entire family deductible before the plan pays benefits. Any one family member, or any combination of family members, can satisfy the deductible.
Balance BillingWhen a provider bills you for the difference between the provider’s charge and the allowed amount under your benefit plan. For example, if the provider’s charge is $100 and the allowed amount under your plan is $70, the provider may bill you for the remaining $30. An in-network provider (sometimes called a preferred provider, depending on your plan) may not balance bill you for covered services.
CoinsuranceThe way you share in the cost for most covered services after you meet the deductible. For example, if the coinsurance amount is 80%, then your medical plan pays 80% of the cost and you pay for the remaining 20% out-of-pocket. When you choose an in-network provider, the coinsurance you pay is significantly lower than for an out-of-network provider.
Co-paymentA fixed amount (for example, $25) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service (e.g., office visit for a pediatrician vs. specialist visit for an orthopedist).
Covered ChargeThe charge for services rendered or supplies furnished by a provider that qualifies as an eligible service and is paid for in whole or in part by your plan. May be subject to deductibles, copayments, coinsurance, or maximum allowable charge, as specified by the terms of the insurance contract.
Covered Service A service or supply (specified in the plan) for which benefits may be available. The plan will not pay for services that are not covered by the plan.
DependentIndividuals who rely on you for support including children and spouse, generally qualify as dependents for health care and insurance benefits.
Emergency Room CareCare received in an emergency room.
Formulary (Prescription Drug Coverage)The Plan includes a list of preferred drugs that are either more effective at treating a particular condition than other drugs in the same class of drugs, or as effective as and less costly than similar medications. Non-preferred (non-formulary) drugs may also be covered under the prescription drug program, but at a higher cost-sharing tier. Collectively, these lists of drugs make up the Plan’s Formulary. The Plan’s Formulary is updated periodically and subject to change. To check where your medications fall within the plan’s formulary please call Express Scripts at 1-866-383-7420.
In-NetworkDoctors and other health care providers, hospitals, clinics, laboratories and outpatient facilities that have negotiated discounted rates with your plan. Depending on your plan, you may have the choice to receive care from either an in-network provider or an out-of- network provider, but you’ll generally pay more if you choose to see an out-of-network provider. In some cases, your plan will refer to network providers as “preferred” providers.
Maximum Allowable Charge (MAC)The limit the plan has determined to be the maximum amount payable for a covered service.
Out-of-NetworkDoctors and other health care providers, hospitals, clinics, laboratories and outpatient facilities that do not have negotiated discounted rates with your plan. You will generally pay more when you receive care from an out-of-network provider because that provider is not bound by contracted pricing. You are responsible for paying the difference between the amount the plan is willing to pay (sometimes called the maximum allowable charge) and the provider’s charge.
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Out-of-Pocket MaximumThe most you will pay during the plan year for in-network care before your plan begins to pay 100% of eligible expenses. This limit does not include your premium or expenses for services not covered by your plan, nor does it include balance billing, amounts above the Maximum Allowable Charge (MAC) for your plan, or out-of-pocket costs for Davis Vision plan services and products. It’s important to check your plan and see what other charges may not be included.
Preferred ProviderA provider who has a contract with your plan to provide services to you at a discount. In some cases, there may be a “preferred network” as a subset of your plan’s overall network. In this instance, preferred providers offer additional savings on covered services.
Primary Care Physician (PCP)A physician who directly provides or coordinates a range of health care services for a patient. You are required to select a primary care physician (PCP) to receive benefits through the HMO plan.
PremiumA health insurance premium is the monthly fee that is paid to an insurance company or health plan to provide health coverage. You and Lehigh both contribute to pay the cost of your premium, with Lehigh paying the majority of the cost.
Prescription DrugsMedications that by law require a prescription.
Preventive CareAny covered service or supply that is received in the absence of symptoms or a diagnosed condition. Preventive care includes preventive health services like physical examinations, certain immunizations, screening tests, and dental cleanings. Preventive care can also provide specific programs of education, exercise, or behavior modification that seek to manage disease or change lifestyle: programs for diabetes management, smoking cessation, childbirth preparation etc. Medical plans clearly define the types of services, supplies, and programs they offer as preventive benefits and they provide them based upon protocols established in the medical community with regard to factors like frequency, patient age, and suitability. The Patient Protection and Affordable Care Act also requires particular preventive services for particular individuals to be covered at no cost, provided the covered services are received from a network provider. These services can be reviewed at www.healthcare.gov/coverage/preventive-care-benefits
SpecialistA specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. The Keystone HMO plan requires a referral to see a specialist, while the PPO plans and the HDHP do not require a referral.
Urgent CareCare for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
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Frequently Asked QuestionsWhen is Open Enrollment?For current employees: Open Enrollment begins on November 4th and ends on November 18th. Open Enrollment is your once-a-year chance to make changes to your benefits. You will not be able to make benefit changes until next year’s Open Enrollment unless you experience a Qualifying Life Event (QLE) (e.g., you get married or have a baby). You must notify Lehigh Benefits of your QLE within 31 days of the event.
For new hires: You must enroll within 30 days of your first day of work.
What changes can I make during Open Enrollment?During enrollment you can:• Change plans• Add or delete dependents from your coverage• Change coverage levels• Enroll in a Health Care or Dependent Care Flexible
Spending Account (FSA), and/or elect the Health Savings Account (HSA) if you enroll in the High Deductible Health Plan (HDHP) option for 2020.
How do I enroll?1. Login to “Connect Lehigh” from the upper left corner of
the Inside Lehigh home page2. Select the Employee tab, then “Lehigh Benefits” from
the list of applications.3. Click on the “Click Here to View Your Benefits” button
and proceed.
You can also now enroll via the Benefitfocus app. 1. Download the Benefitfocus App via the App Store or
the Google Play Store.2. Sign into the system with the ID “lehighbenefits.”3. Log in using your Lehigh ID and password.
Who is eligible for benefits through Lehigh University?You are eligible for benefits if you are a full-time (or work at least 75% of a full work schedule), salaried member of Lehigh’s faculty or staff employed in a benefits-eligible position.
You can also enroll your eligible dependents, including your spouse/partner, child(ren) up to the end of the month in which they become age 26, and disabled child(ren) without age limitation (coverage and its continuation is subject to required certification with the carrier). More information is available through Lehigh Benefits or by calling the Benefits Service Center at 1-844-342-4002.
When will my changes become effective?For current employees: The benefit elections you make during Open Enrollment are effective from January 1, 2020 through December 31, 2020.
For new hires:• Coverage for faculty members is effective as of
their first day of work provided they complete their enrollment in Lehigh Benefits within the first thirty days of employment.
• Coverage for staff members is effective on the first of the month following your start date, provided completed enrollment materials are received within 30 days of your first work day.
What happens if I do not enroll by the deadline?New Employees: If you miss your enrollment period deadline, you will be assigned Lehigh’s default benefit coverage, the PPO plan at an employee cost of $235 per month. No dependents will be enrolled in medical coverage; nor will dental insurance, supplemental or dependent life insurance, or flexible spending accounts be available to you or any dependents.Current Employees: You will receive the same coverage you had in the prior year, with the exception of any flexible spending account or health savings account employee contributions which must be renewed annually.
How do I know what benefits to select? You should select your benefits based on the needs of you and your family, as well as your financial situation. Use the tools available on the Lehigh Benefits website to help you make informed decisions about your benefits.
Are there any changes to the medical plans for 2020?Monthly premiums and out of pocket maximums have increased. See the Your 2020 Medical Options, Summary of Benefits and Coverage and Plan Design Details sections of this publication for information about the plans available to you.
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How do I find a provider?For all medical plans, visit https://www.capbluecross.com and click Find a Provider. You must choose your network in order to see the list of all available in-network providers.
• Select PPO Network for PPO, PPO Plus, and HDHP• Select HMO Network for Keystone
To find a dental provider, visit www.ucci.com and click Find a Dentist. You must select Concordia Advantage Plus as your network before seeing all available in-network providers.
To find a vision provider, visit www.davisvision.com and click Find a Provider.
For all plans other than the Keystone HMO, you have the option to receive care from any provider you choose regardless of whether he or she participates in the plan’s network. Keep in mind that you’ll typically pay more for care when you use out-of-network providers.
What is a Health Savings Account (HSA)?An HSA is a tax-advantaged savings account that you can use like a bank account to pay for qualified medical, dental and vision expenses. You can use the money in your HSA this year or, if you don’t use it now, you can save it for use in the future — even in retirement.
To be eligible to contribute money to an HSA, you must be enrolled in a High Deductible Health Plan (HDHP). See the Health Savings Account (HSA) section to find more information.
If I need more information regarding Open Enrollment, where can I find support?See the Where to Go for Help section on the next page to find contact information for Lehigh’s benefit providers. You may also call the Lehigh Benefits Service Center at 1-844-342-4002.
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Where to Go for HelpContact/Provider Type of Benefit Telephone Number Web Address
Aflac Voluntary Benefits Administration 800-433-3036 www.aflacgroupinsurance.com
Capital Blue Cross and Keystone Health Plan CentralGroup #00515044
Medical Insurance 800-216-9741 www.capbluecross.com
Capital Blue Virtual Care Telehealth 855-818-DOCS www.capbluecross.com/virtualcare
Davis Vision Group #LHU Vision Insurance 877-923-2847 or
800-999-5431www.davisvision.com Control code: 4100Your ID number is your LIN.
Express ScriptsGroup #LEHIGHU Prescriptions Plan 866-383-7420
www.express-scripts.com Create an account for full access.Your ID number is your LIN.
Health Advocate Advocacy Service 866-695-8622 answers@healthadvocate.comwww. healthadvocate.com/members
HealthEquityHealth Savings Account Administration
866-346-5800 www.healthequity.com
Integrated Behavioral Health
Mental Health/Substance Abuse benefits in Keystone Health Plan and PPO Plus
800-395-1616www.ibhcorp.comTo access EAP/Work Life resources:User ID: lehighPassword: univ03
LehighBenefits/Benefitfocus Enroll in your benefits 844-342-4002 Email: LehighBenefits@benefitfocus.com
Magellan Health Services
Mental Health/Substance Abuse benefits in PPO and HDHP
866-322-1657 www.magellanhealth.com/MBH
United ConcordiaGroup #250021021 Dental 800-332-0366 www.ucci.com
WageWorksFlexible Spending Account Administration
855-774-7441 or877-924-3967 www.wageworks.com
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Legal Notices Review the following notices which are required by law to help you understand your rights. If you have any questions, please call Lehigh University Human Resources at 610-758-3900.
Women’s Health and Cancer Rights Act of 1998 (WHCRA) NoticeIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:• all stages of reconstruction of the breast on which the mastectomy was performed;• surgery and reconstruction of the other breast to produce a symmetrical appearance;• prostheses; and • treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call Lehigh’s Human Resources at (610)758-3900.
Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) NoticeUnder federal law, group health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Notices Required By the Patient Protection and Affordable Care ActRetroactive Cancellation of Coverage (Rescission)Your medical benefit cannot be cancelled retroactively except in the case of fraud, intentional misrepresentation of material fact, or failure to pay required contributions on a timely basis. A 30 day notice will be provided if coverage is rescinded. An example of fraud or intentional misrepresentation may include things such as retaining your former spouse on your medical benefits after your divorce decree is final. As a University medical plan participant, it is your responsibility to notify Human Resources of any changes to a dependent’s status within 31 days of a status change event. Failure to provide timely notice to Human Resources constitutes intentional misrepresentation of material fact.
The Designation of Primary Care ProvidersThe Keystone Health Plan Central Health Maintenance Organization Plan (KHPC) generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in the plan network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of participating primary care providers, contact the plan at 800-216-9741. You do not need prior authorization from KHPC or from any other person (including your primary care doctor) in order to obtain access to obstetrical or gynecological care from a health care professional in the plan network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the plan at 800-216-9741.
The ACA’s individual mandate requires that nearly everyone have medical coverage or pay a penalty. If you are benefits-eligible and enroll in a Lehigh health plan, you will be in compliance with the individual mandate.• Our health plans offer the level of coverage to satisfy the individual mandate.• Our health plans offer affordable coverage with at least the minimum benefit value (called “minimum essential
coverage”) required under the ACA.• Anyone can shop in the public health insurance marketplace. While some low-income individuals qualify for subsidized
coverage, Lehigh employees generally will not qualify because of the cost and benefit value of our health plans. • If you shop in the health insurance marketplace, you may find the options offered to be more expensive than the
University’s coverage because Lehigh pays a large part of the cost for your medical coverage. Generally, in the public marketplace, you will pay the entire cost of your coverage.
• For more information about the ACA, visit www.healthcare.gov.
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Premium Assistance Under Medicaid and The Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from youremployer, your state may have a premium assistance program that can help pay for coverage, using funds fromtheir Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t beeligible for these premium assistance programs but you may be able to buy individual insurance coveragethrough the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contactyour State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of yourdependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has aprogram that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible underyour employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.This is called a “special enrollment” opportunity, and you must request coverage within 60 days of beingdetermined eligible for premium assistance. If you have questions about enrolling in your employer plan,contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer healthplan premiums. The following list of states is current as of July 31, 2019. Contact your State for moreinformation on eligibility.
Alabama - Medicaid FLORIDA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment ProgramWebsite: http://myakhipp.com/ Phone: 1-866-251-4861Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medic-aid/default.aspx
Website: https://medicaid.georgia.gov/health-insurance-pre-mium-payment-program-hippPhone: 678-564-1162 ext 2131
ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: http://www.indianamedicaid.comPhone 1-800-403-0864
COLORADO – Health First Colorado (Colorado’s Medicaid Program) &
Child Health Plan Plus (CHP+)
IOWA – Medicaid
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/ State Relay 711
Website: http://www.dhs.iowa.gov/hawkiPhone: 1-888-257-8563
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KANSAS – Medicaid NEVADA – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-785-296-3512
Medicaid Website: http://dhcfp.nv.gov/Medicaid Phone: 1-800-992-0900
KENTUCKY – Medicaid NEW HAMPSHIRE – MedicaidWebsite: http://chfs.ky.gov/Phone: 1-800-635-2570
Website: https://www.dhhs.nh.gov/oii/hipp.htmPhone: 603-271-5218Hotline: NH Medicaid Service Center - 1-888-901-4999
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331Phone: 1-888-695-2447
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 1-800-442-6003TTY: Maine relay 711
Website: https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/eohhs/gof/departments/mass-health/Phone: 1-800-862-4840
Website: https://medicaid.ncdhhs.gov/Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medi-cal-assistance.jspPhone: 1-800-657-3739
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1-844-854-4825
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIPWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005
Website: http://www.insureoklahoma.orgPhone: 1-888-365-3742
MONTANA – Medicaid OREGON – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084
Website: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – MedicaidWebsite: http://www.ACCESSNebraska.ne.govPhone: 1-855-632-7633Lincoln: 402-473-7000Omaha 402-595-1178
Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmPhone: 1-800-692-7462
26
RHODE ISLAND – Medicaid VIRGINIA – Medicaid and CHIPWebsite: http://www.eohhs.ri.gov/Phone: 855-697-4347 or 401-462-0311 (Direct RIte Share Line)
Medicaid Website: http://www.coverva.org/programs_premi-um_assistance.cfmMedicaid Phone: 1-800-432-5924CHIP Website: http://www.coverva.org/programs_premium_assistance.cfmCHIP Phone: 1-855-242-8282
SOUTH CAROLINA – Medicaid WASHINGTON – MedicaidWebsite: http://www.scdhhs.govPhone: 1-888-549-0820
Website: https://www.hca.wa.gov/Phone: 1-800-562-3022 ext. 15473
SOUTH DAKOTA - Medicaid WEST VIRGINIA – MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059
Website: http://mywvhipp.com/Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
TEXAS – Medicaid WISCONSIN – Medicaid and CHIPWebsite: http://gethipptexas.com/Phone: 1-800-440-0493
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdfPhone: 1-800-362-3002
UTAH – Medicaid and CHIP WYOMING – MedicaidMedicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: 1-877-543-7669
Website: https://wyequalitycare.acs-inc.com/Phone: 307-777-7531
VERMONT– MedicaidWebsite: http://www.greenmountaincare.org/Phone: 1-800-250-8427
To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 12/31/2019)
27
Creditable Coverage Disclosure Notice
Important Notice from Lehigh University AboutYour Prescription Drug Coverage and Medicare
October 5, 2019
Please read this notice carefully and keep it where you can find it. This notice has information aboutyour current prescription drug coverage with Lehigh University and about your options underMedicare’s prescription drug coverage. This information can help you decide whether or not youwant to join a Medicare drug plan. If you are considering joining, you should compare your currentcoverage, including which drugs are covered at what cost, with the coverage and costs of the plansoffering Medicare prescription drug coverage in your area. Information about where you can gethelp to make decisions about your prescription drug coverage is at the end of this notice.There are two important things you need to know about your current coverage and Medicare’sprescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Lehigh University has determined that the prescription drug coverage offered by the Express Scripts plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current Lehigh University coverage will not be affected. You can retain your existing coverage and choose not to enroll in a Part D plan now. Or, you can enroll in a Part D plan as a supplement to, or in lieu of, the other coverage. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will still be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current Lehigh University coverage, be aware that you and your dependents will be able to enroll back into the Lehigh University benefit program during the open enrollment period under the plan, providing you are an active, benefits eligible employee at that time.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?You should also know that if you drop or lose your current coverage with Lehigh University and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
28
For More Information About This Notice Or Your Current Prescription Drug Coverage…Contact the person listed below for further information at 610-758-3900. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Lehigh University changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:• Visit www.medicare.gov• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &
You” handbook for their telephone number) for personalized help• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Date: October 5, 2019Name of Entity/Sender: Lehigh UniversityContact – Position/Office: Director of Human Resource ServicesOffice of Human ResourcesAddress: 306 South New Street, Suite 437Bethlehem, PA 18015Phone Number: 610-758-3900
29
Lehigh University Benefit Plans Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Lehigh University sponsors the following employee welfare benefit plans (collectively referred to as the “Plans”):• PPO, administered by Capital Blue Cross,• PPO Plus, administered by Capital Blue Cross,• Keystone Health Plan Central HMO, administered by Capital Blue Cross,• High Deductible Health Plan, administered by Capital Blue Cross,• Behavioral Health Benefits, administered by Magellan Behavioral Health and Integrated Behavioral Health,• Employee Assistance Program, administered by Integrated Behavioral Health,• United Concordia Dental, insured by United Concordia Life and Health Insurance Co.,• Davis Vision, insured by Highmark Blue Shield,• Express Scripts Pharmacy Benefits, administered by Express Scripts,• Health Care Flexible Spending Accounts, administered by WageWorks, and• Health Savings Account, administered by HealthEquity.
The Plans are required by law to maintain the privacy of your health information and to provide you with notice of their legal duties and privacy practices with respect to your health information. If you have any questions about any part of this Notice or if you want more information about the Plans’ privacy practices, please contact:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015Phone: 610-758-3900
How the Plans May Use or Disclose Your Health InformationThe following categories describe the ways that we (the Lehigh University Benefits Staff) may use and disclose your health information. For each category of uses and disclosures, we will explain what we mean and present examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
1. Payment Functions. We may use or disclose health information about you to determine eligibility for plan benefits, obtain premiums, facilitate payment for the treatment and services you receive from health care providers, determine plan responsibility for benefits, and to coordinate benefits. For example, payment functions may include confirmation of eligibility and demographic information to ensure accurate processing of enrollment changes.
2. Health Care Operations. We may use and disclose health information about you to carry out necessary insurance-related activities. For example, such activities may include submitting claims for stop-loss coverage; auditing claims payments; and planning, management, and general administration of the benefits plans.
3. Required by Law. As required by law, we may use or disclose your health information. For example, we may disclose your health information to a law enforcement official for purposes such as complying with a court order or subpoena and other law enforcement purposes; we may disclose your health information in the course of any administrative or judicial proceeding; or we may disclose your health information for military, national security, and government benefits purposes.
4. Health Oversight Activities. We may disclose your health information to health agencies in the course of audits, investigations, or other proceedings related to oversight of the health care system. For example, we will report medical plan enrollment information to the Medicare: Coordination of Benefits IRS/SSA/CMS Data Match Project.
5. Worker’s Compensation. We may disclose your health information as necessary to comply with worker’s compensation or similar laws.
When the Plans May Not Use or Disclose Your Health InformationExcept as described in this Notice of Privacy Policies, we will not use or disclose your health information without written authorization from you. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.
30
Statement of Your Health Information Rights1. Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your
health information. The Plans are not required to agree to the restrictions that you request. If you would like to make a request for restrictions, you must submit your request in writing to:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015
2. Right to Request Confidential Communications. You have the right to receive your health information through a reasonable means or at an alternative location. There are two standard locations used for distribution of plan information. If you are an employee of the University, most information about the plans will be sent to your campus address. On occasion, information may be distributed through the U.S. Postal Service. The standard location for the U.S. Postal Service delivery of plan communications will be your home address, as listed in Lehigh’s records. If you are not a current employee of Lehigh University, our standard location for sending plan information to you is your home address, as listed in Lehigh’s records. To request an alternative means of receiving confidential communications, you must submit your request in writing to:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015
We are not required to agree to your request.
3. Right to Inspect and Copy. You have the right to inspect and copy health information about you that may be used to make decisions about your plan benefits. To inspect and copy such information, you must submit your request in writing to:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015
If you request a copy of the information, we may charge you a reasonable fee to cover expenses associated with your request.
4. Right to Request Amendment. You have the right to request that the Plans amend your health information that you believe is incorrect or incomplete. We are not required to change your health information and, if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must also provide a reason for your request in writing to:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015
5. Right to Accounting of Disclosures. You have the right to receive a list or “accounting of disclosures” of your health information made by us, except that we do not have to account for disclosures made for purposes of payment functions or health care operation, or those made to you. To request this accounting, you must submit your request in writing to:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015
Your request should specify a time period of up to six years and may not include dates beforeApril 14, 2003. The Plans will provide, on request, one list per 12-month period free of charge; we may charge you for additional lists. 31
6. Right to Paper Copy. You have a right to receive a paper copy of this Notice of Privacy Regulations at any time. To obtain a paper copy of this Notice, send your written request to Lehigh University Human Resources, 306 South New Street, Suite 437, Bethlehem, PA 18015. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact:
Director, Human Resource ServicesLehigh University Human Resources306 South New Street, Suite 437Bethlehem, PA 18015Phone: 610-758-3900
Changes to this Notice of Privacy PracticesThe Plans reserve the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice provisions effective for all health information that it maintains. We will promptly revise our Notice and distribute it to you whenever we make material changes to the Notice. Until such time, the Plans are required by law to comply with the current version of this Notice.
ComplaintsComplaints about this Notice of Privacy Practices or about how we handle your health information should be directed to:
Vice President for Finance and AdministrationLehigh University27 Memorial Drive WestBethlehem, PA 18015Phone: 610-758-3178
The Plans will not retaliate against you in any way for filing a complaint. All complaints about the Privacy Practices described in this Notice must be submitted in writing. If you believe your privacy rights have been violated, you may also file a complaint with the Secretary of the Department of Health and Human Services.
Effective Date of This Notice: April 14, 2003; Updated October 21, 2019
32
Summary of Benefits and CoverageAppendix 1
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
[01/
01/2
020
– 12
/31/
2020
] H
igh
Ded
uct
ible
Hea
lth
Pla
n (
HD
HP
): L
ehig
h U
niv
ersi
ty
Co
vera
ge
for:
Indi
vidu
al a
nd F
amily
| P
lan
Typ
e: P
PO
HS
A
Co
vera
ge
for:
___
____
____
__ |
Pla
n T
ype:
___
__
1 o
f 6
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es.
NO
TE
: In
form
atio
n a
bo
ut
the
cost
of
this
pla
n (
calle
d t
he
pre
miu
m)
will
be
pro
vid
ed s
epar
atel
y.
Th
is is
on
ly a
su
mm
ary.
For
mor
e in
form
atio
n ab
out y
our
cove
rage
, or
to g
et a
cop
y of
the
com
plet
e te
rms
of c
over
age:
abo
ut h
ealth
car
e co
vera
ge,
cont
act C
apita
l Blu
e C
ross
at 1
-800
-216
-974
1 or
ww
w.c
apbl
uecr
oss.
com
; abo
ut p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at 1
-866
-383
-742
0 or
w
ww
.exp
ress
-scr
ipts
.com
; and
abo
ut v
isio
n co
vera
ge, c
onta
ct D
avis
Vis
ion
at 1
-800
-999
-543
1 or
ww
w.d
avis
visi
on.c
om. F
or g
ener
al d
efin
ition
s of
com
mon
term
s,
such
as
allo
wed
am
ount
, bal
ance
bill
ing,
coi
nsur
ance
, cop
aym
ent,
dedu
ctib
le, p
rovi
der,
or
othe
r un
derli
ned
term
s se
e th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at
ww
w.c
ciio
.cm
s.go
v or
cal
l 1-8
88-4
28-2
566
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
$1,4
00 in
divi
dual
/ $2
,800
fam
ily
part
icip
atin
g pr
ovid
ers;
$2,
500
indi
vidu
al
/ $5,
000
fam
ily n
on-p
artic
ipat
ing
prov
ider
s. D
educ
tible
app
lies
to a
ll se
rvic
es, i
nclu
ding
pre
scrip
tion
drug
, be
fore
any
cop
aym
ent o
r co
insu
ranc
e ar
e ap
plie
d.
Gen
eral
ly, y
ou m
ust p
ay a
ll th
e co
sts
from
pro
vide
rs u
p to
the
dedu
ctib
le a
mou
nt b
efor
e th
is p
lan
begi
ns to
pay
. If
you
have
oth
er fa
mily
mem
bers
on
the
plan
, eac
h fa
mily
mem
ber
mus
t mee
t the
ir ow
n in
divi
dual
ded
uctib
le u
ntil
the
tota
l am
ount
of d
educ
tible
exp
ense
s pa
id b
y al
l fam
ily m
embe
rs m
eets
the
over
all f
amily
ded
uctib
le.
Are
th
ere
serv
ices
co
vere
d b
efo
re y
ou
mee
t yo
ur
ded
uct
ible
?
Yes
. N
etw
ork
prev
entiv
e se
rvic
es.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t yet
met
the
dedu
ctib
le
amou
nt.
But
a c
opay
men
t or
coin
sura
nce
may
app
ly.
For
exa
mpl
e, th
is p
lan
cove
rs
cert
ain
prev
entiv
e se
rvic
es w
ithou
t cos
t-sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
. S
ee
a lis
t of c
over
ed p
reve
ntiv
e se
rvic
es a
t http
s://w
ww
.hea
lthca
re.g
ov/c
over
age/
prev
entiv
e-
care
-ben
efits
/.
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it f
or
this
pla
n?
For
par
ticip
atin
g pr
ovid
ers
$6,9
00
indi
vidu
al /
$13,
800
fam
ily; f
or n
on-
part
icip
atin
g pr
ovid
ers
$0 in
divi
dual
co
mbi
ned
out-
of-p
ocke
t lim
it fo
r m
edic
al
and
pres
crip
tion
drug
.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet t
heir
own
out-
of-p
ocke
t lim
its
until
the
over
all f
amily
out
-of-
pock
et li
mit
has
been
met
.
Wh
at is
no
t in
clu
ded
in
the
ou
t-o
f-p
ock
et li
mit
?
Pre
-aut
horiz
atio
n pe
nalti
es, p
rem
ium
s,
bala
nce
billi
ng c
harg
es, v
isio
n ca
re
cost
s, a
nd h
ealth
car
e th
is p
lan
does
n't
cove
r.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
war
d th
e ou
t-of
-poc
ket l
imit.
2 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Will
yo
u p
ay le
ss if
yo
u
use
a n
etw
ork
pro
vid
er?
Yes
. For
a li
st o
f par
ticip
atin
g pr
ovid
ers,
se
e w
ww
.cap
blue
cros
s.co
m o
r ca
ll 1-
800-
962-
2242
. See
w
ww
.dav
isvi
sion
.com
or
call
1-80
0-99
9-54
31 fo
r vi
sion
car
e pa
rtic
ipat
ing
prov
ider
s.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
's
netw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd y
ou m
ight
re
ceiv
e a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er's
cha
rge
and
wha
t yo
ur p
lan
pays
(ba
lanc
e bi
lling
). B
e aw
are
your
net
wor
k pr
ovid
er m
ight
use
an
out-
of-
netw
ork
prov
ider
for
som
e se
rvic
es (
such
as
lab
wor
k).
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces.
Do
yo
u n
eed
a r
efer
ral t
o
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l.
3 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
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/con
nect
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C-P
ublic
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C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
All
cop
aym
ent
and
coin
sura
nce
cos
ts s
how
n in
this
cha
rt a
re a
fter
your
ded
uct
ible
has
bee
n m
et, i
f a d
edu
ctib
le a
pplie
s.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
’s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
Spe
cial
ist v
isit
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
Man
date
d sc
reen
ing
and
imm
uniz
atio
ns 3
0%
coin
sura
nce;
Rou
tine
Phy
sica
l exa
ms;
Not
co
vere
d
Ded
uctib
le d
oes
not a
pply
to s
ervi
ces
at
part
icip
atin
g pr
ovid
ers.
You
may
hav
e to
pay
fo
r se
rvic
es th
at a
ren'
t pre
vent
ive.
Ask
you
r pr
ovid
er if
the
serv
ices
you
nee
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our
plan
will
pay
for.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
w
ork)
20%
coi
nsur
ance
for
lab
and
20%
coi
nsur
ance
for
test
s. 2
0% c
oins
uran
ce
for
outp
atie
nt r
adio
logy
.
30%
coi
nsur
ance
N
one
Imag
ing
(CT
/PE
T s
cans
, M
RIs
)
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on
dru
g c
ove
rag
e
is a
vaila
ble
at w
ww
.exp
ress
-sc
rip
ts.c
om
or
call
1-86
6-38
3-74
20.
Gen
eric
dru
gs
10%
coi
nsur
ance
(r
etai
l an
d m
ail o
rder
)
10%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Pre
ferr
ed b
rand
dru
gs
20%
coi
nsur
ance
(ret
ail a
nd m
ail o
rder
)
20%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
sup
ply.
Som
e dr
ugs
may
re
quire
pre
auth
oriz
atio
n. If
the
nece
ssar
y pr
eaut
horiz
atio
n is
not
obt
aine
d, th
e dr
ug m
ay
not b
e co
vere
d.
Non
-pre
ferr
ed b
rand
dru
gs
30%
coi
nsur
ance
(r
etai
l and
mai
l ord
er)
30%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Spe
cial
ty d
rugs
20%
coi
nsur
ance
for
pref
erre
d br
and
drug
s an
d 30
% c
oins
uran
ce
For
non
-pre
ferr
ed b
rand
dr
ugs
Not
cov
ered
S
ome
drug
s m
ay r
equi
re p
urch
ase
thro
ugh
Acc
redo
Spe
cial
ty P
harm
acy.
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
) 20
% c
oins
uran
ce
30%
coi
nsur
ance
S
ervi
ces
at n
on-p
artic
ipat
ing
ambu
lato
ry
surg
ical
faci
litie
s 30
% c
oins
uran
ce.
4 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
an/s
urge
on fe
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e 20
% c
oins
uran
ce
20%
coi
nsur
ance
N
one
Em
erge
ncy
med
ical
tr
ansp
orta
tion
20%
coi
nsur
ance
20
% c
oins
uran
ce
Non
e
Urg
ent c
are
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
If y
ou
hav
e a
ho
spit
al s
tay
Fac
ility
fee
(e.g
., ho
spita
l ro
om)
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Phy
sici
an/s
urge
on fe
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
If y
ou
nee
d m
enta
l hea
lth
, b
ehav
iora
l hea
lth
, or
sub
stan
ce a
bu
se s
ervi
ces
Out
patie
nt s
ervi
ces
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
Inpa
tient
ser
vice
s 20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
If y
ou
are
pre
gn
ant
Offi
ce v
isits
20
% c
oins
uran
ce
30%
coi
nsur
ance
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s, a
co
paym
ent,
coin
sura
nce,
or
dedu
ctib
le m
ay
appl
y.
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
ser
vice
s 20
% c
oins
uran
ce
30%
coi
nsur
ance
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
20
% c
oins
uran
ce
30%
coi
nsur
ance
If y
ou
nee
d h
elp
rec
ove
rin
g
or
hav
e o
ther
sp
ecia
l h
ealt
h n
eed
s
Hom
e he
alth
car
e 20
% c
oins
uran
ce
30%
coi
nsur
ance
90
vis
it lim
it *S
ee p
reau
thor
izat
ion
sche
dule
at
tach
ed to
you
r ce
rtifi
cate
of c
over
age.
Reh
abili
tatio
n se
rvic
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
Ski
lled
nurs
ing
care
20
% c
oins
uran
ce
30%
coi
nsur
ance
10
0 da
y lim
it
Dur
able
med
ical
equ
ipm
ent
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Hos
pice
ser
vice
s 20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Mo
re in
form
atio
n a
bo
ut
par
tici
pat
ing
pro
vid
ers
and
vi
sio
n c
are
ben
efit
s ar
e av
aila
ble
at
ww
w.d
avis
visi
on
.co
m o
r ca
ll 1-
800-
999-
5431
.
Chi
ldre
n’s
eye
exam
N
o ch
arge
F
ull c
ost l
ess
$32
Lim
ited
to o
ne e
xam
per
yea
r
Chi
ldre
n’s
glas
ses
No
char
ge fo
r st
anda
rd
lens
es a
nd s
elec
t fr
ames
; Am
ount
ove
r $6
0 fo
r pr
ovid
er fr
ames
Ful
l cos
t les
s $5
5 fo
r st
anda
rd le
nses
and
any
fr
ame
Lim
ited
to o
ne p
air
of g
lass
es p
er y
ear
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
5 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s.)
Acu
punc
ture
Bar
iatr
ic S
urge
ry (
unle
ss m
edic
ally
nec
essa
ry)
Cos
met
ic S
urge
ry
Den
tal c
are
Hea
ring
aids
Long
-ter
m c
are
Rou
tine
foot
car
e (u
nles
s m
edic
ally
nec
essa
ry)
Wei
ght l
oss
prog
ram
s
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
Chi
ropr
actic
Car
e
Infe
rtili
ty tr
eatm
ent
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
.
Priv
ate-
duty
nur
sing
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: 1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. Oth
er c
over
age
optio
ns m
ay b
e av
aila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l, or
a g
rieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
for
heal
th c
are
cove
rage
, con
tact
Cap
ital B
lue
Cro
ss a
t 1-8
00-2
16-9
741
or w
ww
.cap
blue
cros
s.co
m; f
or p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at
1-8
66-3
83-7
420
or w
ww
.exp
ress
-scr
ipts
.com
; and
for
visi
on c
over
age,
con
tact
Dav
is V
isio
n at
1-8
00-9
99-5
431
or w
ww
.dav
isvi
sion
.com
. or
the
Dep
artm
ent o
f La
bor’s
Em
ploy
ee B
enef
it S
ecur
ity A
dmin
istr
atio
n at
1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e?
Yes
If
you
don’
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
, you
’ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th.
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds?
Y
es
If yo
ur p
lan
does
n’t m
eet t
he M
inim
um V
alue
Sta
ndar
ds, y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
. L
ang
uag
e A
cces
s S
ervi
ces:
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[Nav
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isin
go, k
wiij
igo
holn
e' [i
nser
t tel
epho
ne n
umbe
r].]
––
––––
––––
––––
––––
––––
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n, s
ee th
e ne
xt s
ectio
n.––
––––
––––
––––
––––
––––
6 o
f 6
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in
-net
wor
k em
erge
ncy
room
vis
it an
d fo
llow
up
car
e)
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a
yea
r of
rou
tine
in-n
etw
ork
care
of a
wel
l-co
ntro
lled
cond
ition
)
T
he
pla
n’s
ove
rall
ded
uct
ible
$1
400
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth/
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth/
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12,
700
In t
his
exa
mp
le, P
eg w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$1,4
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
,523
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
,983
T
he
pla
n’s
ove
rall
ded
uct
ible
$1
400
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
,400
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$1,4
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
,369
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$2,8
29
T
he
pla
n’s
ove
rall
ded
uct
ible
$1
400
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$1,9
00
In t
his
exa
mp
le, M
ia w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$1,4
00
Cop
aym
ents
$0
Coi
nsur
ance
$3
85
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
,785
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
cost
s yo
u m
ight
pay
und
er d
iffer
ent h
ealth
pla
ns. P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e.
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
[01/
01/2
020
– 12
/31/
2020
] P
refe
rred
Pro
vid
er O
rgan
izat
ion
Pla
n (
PP
O):
Leh
igh
Un
iver
sity
C
ove
rag
e fo
r: In
divi
dual
and
Fam
ily |
Pla
n T
ype:
PP
O
Co
vera
ge
for:
___
____
____
__ |
Pla
n T
ype:
___
__
1 o
f 7
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es.
NO
TE
: In
form
atio
n a
bo
ut
the
cost
of
this
pla
n (
calle
d t
he
pre
miu
m)
will
be
pro
vid
ed s
epar
atel
y.
Th
is is
on
ly a
su
mm
ary.
For
mor
e in
form
atio
n ab
out y
our
cove
rage
, or
to g
et a
cop
y of
the
com
plet
e te
rms
of c
over
age:
abo
ut h
ealth
car
e co
vera
ge,
cont
act C
apita
l Blu
e C
ross
at 1
-800
-216
-974
1 or
ww
w.c
apbl
uecr
oss.
com
; abo
ut p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at 1
-866
-383
-742
0 or
w
ww
.exp
ress
-scr
ipts
.com
; and
abo
ut v
isio
n co
vera
ge, c
onta
ct D
avis
Vis
ion
at 1
-800
-999
-543
1 or
ww
w.d
avis
visi
on.c
om. F
or g
ener
al d
efin
ition
s of
com
mon
term
s,
such
as
allo
wed
am
ount
, bal
ance
bill
ing,
coi
nsur
ance
, cop
aym
ent,
dedu
ctib
le, p
rovi
der,
or
othe
r un
derli
ned
term
s se
e th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at
ww
w.c
ciio
.cm
s.go
v or
cal
l 1-8
88-4
28-2
566
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
$200
/indi
vidu
al/$
600/
fam
ily p
artic
ipat
ing
prov
ider
s; $
500/
indi
vidu
al n
on-p
artic
ipat
ing
prov
ider
s.
Gen
eral
ly, y
ou m
ust p
ay a
ll th
e co
sts
from
pro
vide
rs u
p to
the
dedu
ctib
le a
mou
nt
befo
re th
is p
lan
begi
ns to
pay
. If
you
have
oth
er fa
mily
mem
bers
on
the
plan
, eac
h fa
mily
mem
ber
mus
t mee
t the
ir ow
n in
divi
dual
ded
uctib
le u
ntil
the
tota
l am
ount
of
dedu
ctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
.
Are
th
ere
serv
ices
co
vere
d b
efo
re y
ou
mee
t yo
ur
ded
uct
ible
?
Yes
. N
etw
ork
prev
entiv
e se
rvic
es.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t yet
met
the
dedu
ctib
le
amou
nt.
But
a c
opay
men
t or
coin
sura
nce
may
app
ly.
For
exa
mpl
e, th
is p
lan
cove
rs
cert
ain
prev
entiv
e se
rvic
es w
ithou
t cos
t-sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
. S
ee a
list
of c
over
ed p
reve
ntiv
e se
rvic
es a
t ht
tps:
//ww
w.h
ealth
care
.gov
/cov
erag
e/pr
even
tive
-car
e-be
nefit
s/.
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it f
or
this
pla
n?
For
par
ticip
atin
g pr
ovid
ers
$4,0
00 in
divi
dual
/ $8
,000
fam
ily; f
or n
on-p
artic
ipat
ing
prov
ider
s $0
indi
vidu
al c
ombi
ned
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n dr
ug.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If yo
u
have
oth
er fa
mily
mem
bers
in th
is p
lan,
they
hav
e to
mee
t the
ir ow
n ou
t-of
-poc
ket l
imits
un
til th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
Wh
at is
no
t in
clu
ded
in
the
ou
t-o
f-p
ock
et li
mit
?
Pre
-aut
horiz
atio
n pe
nalti
es, p
rem
ium
s,
bala
nce
billi
ng c
harg
es, v
isio
n ca
re c
osts
, an
d he
alth
car
e th
is p
lan
does
n't c
over
.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
war
d th
e ou
t-of
-poc
ket l
imit.
Will
yo
u p
ay le
ss if
yo
u
use
a n
etw
ork
pro
vid
er?
Yes
. For
a li
st o
f par
ticip
atin
g pr
ovid
ers,
see
w
ww
.cap
blue
cros
s.co
m o
r ca
ll 1-
800-
962-
2242
. See
ww
w.d
avis
visi
on.c
om o
r ca
ll 1-
800-
999-
5431
for
visi
on c
are
part
icip
atin
g pr
ovid
ers.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
's
netw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd y
ou m
ight
re
ceiv
e a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er's
cha
rge
and
wha
t yo
ur p
lan
pays
(ba
lanc
e bi
lling
). B
e aw
are
your
net
wor
k pr
ovid
er m
ight
use
an
out-
of-
netw
ork
prov
ider
for
som
e se
rvic
es (
such
as
lab
wor
k).
Che
ck w
ith y
our
prov
ider
be
fore
you
get
ser
vice
s.
2 o
f 7
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Do
yo
u n
eed
a r
efer
ral t
o
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l.
3 o
f 7
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
All
cop
aym
ent
and
coin
sura
nce
cos
ts s
how
n in
this
cha
rt a
re a
fter
your
ded
uct
ible
has
bee
n m
et, i
f a d
edu
ctib
le a
pplie
s.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
ca
re p
rovi
der
’s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry
or il
lnes
s $2
5 co
paym
ent/v
isit
30%
coi
nsur
ance
N
one
Spe
cial
ist v
isit
$40
copa
ymen
t/vis
it 30
% c
oins
uran
ce
Non
e
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
Man
date
d sc
reen
ing
and
imm
uniz
atio
ns 3
0%
coin
sura
nce;
Rou
tine
Phy
sica
l exa
ms;
Not
co
vere
d
Ded
uctib
le d
oes
not a
pply
to s
ervi
ces
at
part
icip
atin
g pr
ovid
ers.
You
may
hav
e to
pay
fo
r se
rvic
es th
at a
ren'
t pre
vent
ive.
Ask
you
r pr
ovid
er if
the
serv
ices
you
nee
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our
plan
will
pay
for.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
wor
k)
20%
coi
nsur
ance
for
lab
and
20%
coi
nsur
ance
for
test
s. 2
0% c
oins
uran
ce
for
outp
atie
nt r
adio
logy
.
30%
coi
nsur
ance
N
one
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
20
% c
oins
uran
ce
30%
coi
nsur
ance
*S
ee p
reau
thor
izat
ion
sche
dule
atta
ched
to
your
cer
tific
ate
of c
over
age.
If y
ou
nee
d d
rug
s to
tr
eat
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on
dru
g
cove
rag
e is
ava
ilabl
e at
w
ww
.exp
ress
-sc
rip
ts.c
om
or
call
1-86
6-38
3-74
20.
Gen
eric
dru
gs
10%
coi
nsur
ance
(r
etai
l an
d m
ail o
rder
)
10%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Pre
ferr
ed b
rand
dru
gs
20%
coi
nsur
ance
(ret
ail a
nd m
ail o
rder
)
20%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Non
-pre
ferr
ed b
rand
dru
gs
30%
coi
nsur
ance
(r
etai
l and
mai
l ord
er)
30%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Spe
cial
ty d
rugs
20%
coi
nsur
ance
for
pref
erre
d br
and
drug
s an
d 30
% c
oins
uran
ce
For
non
-pre
ferr
ed b
rand
dr
ugs
Not
cov
ered
S
ome
drug
s m
ay r
equi
re p
urch
ase
thro
ugh
A
ccre
do S
peci
alty
Pha
rmac
y.
4 o
f 7
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
) 20
% c
oins
uran
ce
30%
coi
nsur
ance
S
ervi
ces
at n
on-p
artic
ipat
ing
ambu
lato
ry
surg
ical
faci
litie
s 30
% c
oins
uran
ce.
Phy
sici
an/s
urge
on fe
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
00 c
opay
men
t/vis
it $1
00 c
opay
men
t/vis
it D
educ
tible
doe
s no
t app
ly.
Cop
aym
ent w
aive
d if
adm
itted
inpa
tient
.
Em
erge
ncy
med
ical
tran
spor
tatio
n 20
% c
oins
uran
ce
30%
coi
nsur
ance
D
educ
tible
doe
s no
t app
ly.
Urg
ent c
are
$40
copa
ymen
t/vis
it 30
% c
oins
uran
ce
Non
e
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Phy
sici
an/s
urge
on fe
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
If y
ou
nee
d m
enta
l h
ealt
h, b
ehav
iora
l h
ealt
h, o
r su
bst
ance
ab
use
ser
vice
s
Out
patie
nt s
ervi
ces
$25
copa
ymen
t/vis
it 30
% c
oins
uran
ce
Non
e
Inpa
tient
ser
vice
s 20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
If y
ou
are
pre
gn
ant
Offi
ce v
isits
$4
0 co
paym
ent/v
isit
30%
coi
nsur
ance
D
epen
ding
on
the
type
of s
ervi
ces,
a
copa
ymen
t, co
insu
ranc
e, o
r de
duct
ible
may
ap
ply.
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
se
rvic
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
20
% c
oins
uran
ce
30%
coi
nsur
ance
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er s
pec
ial h
ealt
h
nee
ds
Hom
e he
alth
car
e 20
% c
oins
uran
ce
30%
coi
nsur
ance
90
vis
it lim
it *S
ee p
reau
thor
izat
ion
sche
dule
at
tach
ed to
you
r ce
rtifi
cate
of c
over
age.
Reh
abili
tatio
n se
rvic
es
20%
coi
nsur
ance
30
% c
oins
uran
ce
Non
e
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
Ski
lled
nurs
ing
care
20
% c
oins
uran
ce
30%
coi
nsur
ance
10
0 da
y lim
it
Dur
able
med
ical
equ
ipm
ent
20%
coi
nsur
ance
30
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Hos
pice
ser
vice
s 20
% c
oins
uran
ce
30%
coi
nsur
ance
N
one
If y
ou
r ch
ild n
eed
s d
enta
l or
eye
care
--
Mo
re in
form
atio
n
abo
ut
par
tici
pat
ing
p
rovi
der
s an
d v
isio
n
Chi
ldre
n’s
eye
exam
N
o ch
arge
F
ull c
ost l
ess
$32
Lim
ited
to o
ne e
xam
per
yea
r
Chi
ldre
n’s
glas
ses
No
char
ge fo
r st
anda
rd
lens
es a
nd s
elec
t fr
ames
; Am
ount
ove
r $6
0 fo
r pr
ovid
er fr
ames
Ful
l cos
t les
s $5
5 fo
r st
anda
rd le
nses
and
any
fr
ame
Lim
ited
to o
ne p
air
of g
lass
es p
er y
ear
5 o
f 7
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
care
ben
efit
s ar
e av
aila
ble
at
ww
w.d
avis
visi
on
.co
m
or
call
1-80
0-99
9-54
31.
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s.)
Acu
punc
ture
Bar
iatr
ic S
urge
ry (
unle
ss m
edic
ally
nec
essa
ry)
Cos
met
ic S
urge
ry
Den
tal c
are
Hea
ring
aids
Long
-ter
m c
are
Rou
tine
foot
car
e (u
nles
s m
edic
ally
nec
essa
ry)
Wei
ght l
oss
prog
ram
s
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
Chi
ropr
actic
Car
e
Infe
rtili
ty tr
eatm
ent
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
.
Priv
ate-
duty
nur
sing
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: 1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. Oth
er c
over
age
optio
ns m
ay b
e av
aila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l, or
a g
rieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
for
heal
th c
are
cove
rage
, con
tact
Cap
ital B
lue
Cro
ss a
t 1-8
00-2
16-9
741
or w
ww
.cap
blue
cros
s.co
m; f
or p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at
1-8
66-3
83-7
420
or w
ww
.exp
ress
-scr
ipts
.com
; and
for
visi
on c
over
age,
con
tact
Dav
is V
isio
n at
1-8
00-9
99-5
431
or w
ww
.dav
isvi
sion
.com
. or
the
Dep
artm
ent o
f La
bor’s
Em
ploy
ee B
enef
it S
ecur
ity A
dmin
istr
atio
n at
1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e?
Yes
If
you
don’
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
, you
’ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th.
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds?
Y
es
If yo
ur p
lan
does
n’t m
eet t
he M
inim
um V
alue
Sta
ndar
ds, y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
. L
ang
uag
e A
cces
s S
ervi
ces:
6 o
f 7
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
[Spa
nish
(E
spañ
ol):
Par
a ob
tene
r as
iste
ncia
en
Esp
añol
, lla
me
al [i
nser
t tel
epho
ne n
umbe
r].]
[Tag
alog
(T
agal
og):
Kun
g ka
ilang
an n
inyo
ang
tulo
ng s
a T
agal
og tu
maw
ag
sa [i
nser
t tel
epho
ne n
umbe
r].]
[Chi
nese
(中文
): 如果需要中文的帮助,请拨打这个号码
[ins
ert t
elep
hone
num
ber]
.]
[Nav
ajo
(Din
e): D
inek
'ehg
o sh
ika
at'o
hwol
nin
isin
go, k
wiij
igo
holn
e' [i
nser
t tel
epho
ne n
umbe
r].]
––
––––
––––
––––
––––
––––
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n, s
ee th
e ne
xt s
ectio
n.––
––––
––––
––––
––––
––––
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in
-net
wor
k em
erge
ncy
room
vis
it an
d fo
llow
up
car
e)
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a
yea
r of
rou
tine
in-n
etw
ork
care
of a
wel
l-co
ntro
lled
cond
ition
)
T
he
pla
n’s
ove
rall
ded
uct
ible
$2
00
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth/
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth/
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12,
700
In t
his
exa
mp
le, P
eg w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$200
Cop
aym
ents
$5
0
Coi
nsur
ance
$2
,490
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$2
,800
T
he
pla
n’s
ove
rall
ded
uct
ible
$2
00
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s li
ke:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
)
To
tal E
xam
ple
Co
st
$7,4
00
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$200
Cop
aym
ents
$2
80
Coi
nsur
ance
$1
,160
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$1,7
00
T
he
pla
n’s
ove
rall
ded
uct
ible
$2
00
S
pec
ialis
t [c
ost
sh
arin
g]
$40
H
osp
ital
(fa
cilit
y) [
cost
sh
arin
g]
20%
Oth
er [
cost
sh
arin
g]
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$1,9
00
In t
his
exa
mp
le, M
ia w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$200
Cop
aym
ents
$1
20
Coi
nsur
ance
$3
30
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$6
50
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
cost
s yo
u m
ight
pay
und
er d
iffer
ent
hea
lth p
lans
. Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age.
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
[01/
01/2
020
– 12
/31/
2020
] P
refe
rred
Pro
vid
er O
rgan
izat
ion
Pla
n (
PP
O P
lus)
: L
ehig
h U
niv
ersi
ty
Co
vera
ge
for:
Indi
vidu
al a
nd F
amily
| P
lan
Typ
e: P
PO
C
ove
rag
e fo
r: _
____
____
____
| P
lan
Typ
e: _
____
1 o
f 6
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es.
NO
TE
: In
form
atio
n a
bo
ut
the
cost
of
this
pla
n (
calle
d t
he
pre
miu
m)
will
be
pro
vid
ed s
epar
atel
y.
Th
is is
on
ly a
su
mm
ary.
For
mor
e in
form
atio
n ab
out y
our
cove
rage
, or
to g
et a
cop
y of
the
com
plet
e te
rms
of c
over
age:
abo
ut h
ealth
car
e co
vera
ge,
cont
act C
apita
l Blu
e C
ross
at 1
-800
-216
-974
1 or
ww
w.c
apbl
uecr
oss.
com
; abo
ut p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at 1
-866
-383
-742
0 or
w
ww
.exp
ress
-scr
ipts
.com
; abo
ut m
enta
l/beh
avio
ral h
ealth
or
subs
tanc
e ab
use,
con
tact
Inte
grat
ed B
ehav
iora
l Hea
lth a
t 1-8
00-3
95-1
616
or w
ww
.ibhc
orp.
com
; and
ab
out v
isio
n co
vera
ge, c
onta
ct D
avis
Vis
ion
at 1
-800
-999
-543
1 or
ww
w.d
avis
visi
on.c
om. F
or g
ener
al d
efin
ition
s of
com
mon
term
s, s
uch
as a
llow
ed a
mou
nt, b
alan
ce
billi
ng, c
oins
uran
ce, c
opay
men
t, de
duct
ible
, pro
vide
r, o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.c
ciio
.cm
s.go
v or
cal
l 1-8
88-
428-
2566
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
$0
/indi
vidu
al p
artic
ipat
ing
prov
ider
s;
$500
/indi
vidu
al n
on-p
artic
ipat
ing
prov
ider
s.
Gen
eral
ly, y
ou m
ust p
ay a
ll th
e co
sts
from
pro
vide
rs u
p to
the
dedu
ctib
le
amou
nt b
efor
e th
is p
lan
begi
ns to
pay
. If
you
have
oth
er fa
mily
mem
bers
on
the
plan
, eac
h fa
mily
mem
ber
mus
t mee
t the
ir ow
n in
divi
dual
ded
uctib
le u
ntil
the
tota
l am
ount
of
dedu
ctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
.
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le?
Yes
. E
mer
genc
y se
rvic
es o
r em
erge
ncy
med
ical
tran
spor
tatio
n, a
nd n
etw
ork
prev
entiv
e se
rvic
es.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t yet
met
the
dedu
ctib
le a
mou
nt.
But
a c
opay
men
t or
coin
sura
nce
may
app
ly.
For
ex
ampl
e, th
is p
lan
cove
rs c
erta
in p
reve
ntiv
e se
rvic
es w
ithou
t cos
t-sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
. S
ee a
list
of c
over
ed p
reve
ntiv
e se
rvic
es a
t ht
tps:
//ww
w.h
ealth
care
.gov
/cov
erag
e/pr
even
tive
-car
e-be
nefit
s/.
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n?
For
par
ticip
atin
g pr
ovid
ers
$4,0
00 in
divi
dual
/ $8
,000
fam
ily; f
or n
on-p
artic
ipat
ing
prov
ider
s $0
indi
vidu
al c
ombi
ned
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n dr
ug.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet
thei
r ow
n ou
t-of
-poc
ket l
imits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
Wh
at is
no
t in
clu
ded
in
the
ou
t-o
f-p
ock
et li
mit
?
Pre
-aut
horiz
atio
n p
enal
ties,
pre
miu
ms,
ba
lanc
e bi
lling
cha
rges
, vis
ion
care
cos
ts, a
nd
heal
th c
are
this
pla
n do
esn'
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
war
d th
e ou
t-of
-po
cket
lim
it.
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er?
Yes
. For
a li
st o
f par
ticip
atin
g pr
ovid
ers,
see
w
ww
.cap
blue
cros
s.co
m o
r ca
ll 1-
800-
962-
2242
. Cal
l IB
H a
t 1-8
00-3
95-1
616
for
men
tal/b
ehav
iora
l hea
lth o
r su
bsta
nce
abus
e
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
th
e pl
an's
net
wor
k. Y
ou w
ill p
ay th
e m
ost i
f you
use
an
out-
of-n
etw
ork
prov
ider
, and
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er's
cha
rge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
. B
e
2 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
prov
ider
s. S
ee w
ww
.dav
isvi
sion
.com
or
call
1-80
0-99
9-54
31 fo
r vi
sion
car
e pa
rtic
ipat
ing
prov
ider
s.
awar
e yo
ur n
etw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
. C
heck
with
you
r pr
ovid
er b
efor
e yo
u ge
t se
rvic
es.
Do
yo
u n
eed
a r
efer
ral t
o s
ee a
sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l.
3 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
All
cop
aym
ent
and
coin
sura
nce
cos
ts s
how
n in
this
cha
rt a
re a
fter
your
ded
uct
ible
has
bee
n m
et, i
f a d
edu
ctib
le a
pplie
s.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
ca
re p
rovi
der
’s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry
or il
lnes
s $2
5 co
paym
ent/v
isit
20%
coi
nsur
ance
N
one
Spe
cial
ist v
isit
$40
copa
ymen
t/vis
it 20
% c
oins
uran
ce
Non
e
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
Man
date
d sc
reen
ing
and
imm
uniz
atio
ns 2
0%
coin
sura
nce;
Rou
tine
Phy
sica
l exa
ms;
Not
co
vere
d
Ded
uctib
le d
oes
not a
pply
to s
ervi
ces
at
part
icip
atin
g pr
ovid
ers.
You
may
hav
e to
pay
fo
r se
rvic
es th
at a
ren'
t pre
vent
ive.
Ask
you
r pr
ovid
er if
the
serv
ices
you
nee
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our
plan
will
pay
for.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
wor
k)
10%
coi
nsur
ance
for
lab
and
10%
coi
nsur
ance
for
test
s. 1
0% c
oins
uran
ce
for
outp
atie
nt r
adio
logy
.
20%
coi
nsur
ance
N
one
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
10
% c
oins
uran
ce
20%
coi
nsur
ance
*S
ee p
reau
thor
izat
ion
sche
dule
atta
ched
to
your
cer
tific
ate
of c
over
age.
If y
ou
nee
d d
rug
s to
tr
eat
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on
dru
g
cove
rag
e is
ava
ilabl
e at
w
ww
.exp
ress
-sc
rip
ts.c
om
or
call
1-86
6-38
3-74
20.
Gen
eric
dru
gs
10%
coi
nsur
ance
(r
etai
l an
d m
ail o
rder
)
10%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Pre
ferr
ed b
rand
dru
gs
20%
coi
nsur
ance
(ret
ail a
nd m
ail o
rder
)
20%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Non
-pre
ferr
ed b
rand
dru
gs
30%
coi
nsur
ance
(r
etai
l and
mai
l ord
er)
30%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Spe
cial
ty d
rugs
20%
coi
nsur
ance
for
pref
erre
d br
and
drug
s an
d 30
% c
oins
uran
ce
For
non
-pre
ferr
ed b
rand
dr
ugs
Not
cov
ered
S
ome
drug
s m
ay r
equi
re p
urch
ase
thro
ugh
Acc
redo
Spe
cial
ty P
harm
acy.
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
) 10
% c
oins
uran
ce
20%
coi
nsur
ance
S
ervi
ces
at n
on-p
artic
ipat
ing
ambu
lato
ry
surg
ical
faci
litie
s 30
% c
oins
uran
ce.
4 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
an/s
urge
on fe
es
10%
coi
nsur
ance
20
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
00 c
opay
men
t/vis
it $1
00 c
opay
men
t/vis
it C
opay
men
t wai
ved
if ad
mitt
ed in
patie
nt.
Em
erge
ncy
med
ical
tran
spor
tatio
n 10
% c
oins
uran
ce
10%
coi
nsur
ance
N
one
Urg
ent c
are
$40
copa
ymen
t/vis
it 20
% c
oins
uran
ce
Non
e
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
10%
coi
nsur
ance
20
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Phy
sici
an/s
urge
on fe
es
10%
coi
nsur
ance
20
% c
oins
uran
ce
Non
e
If y
ou
nee
d m
enta
l h
ealt
h, b
ehav
iora
l h
ealt
h, o
r su
bst
ance
ab
use
ser
vice
s
Out
patie
nt s
ervi
ces
$25
copa
ymen
t/vis
it 20
% c
oins
uran
ce
Som
e se
rvic
es r
equi
re p
re-c
ertif
icat
ion.
Inpa
tient
ser
vice
s 10
% c
oins
uran
ce
20%
coi
nsur
ance
P
re-c
ertif
icat
ion
requ
ired.
50%
co
-insu
ranc
e fo
r se
rvic
es p
rovi
ded
with
out p
re-a
utho
rizat
ion.
If y
ou
are
pre
gn
ant
Offi
ce v
isits
$4
0 co
paym
ent/v
isit
20%
coi
nsur
ance
D
epen
ding
on
the
type
of s
ervi
ces,
a
copa
ymen
t, co
insu
ranc
e, o
r de
duct
ible
may
ap
ply.
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
se
rvic
es
10%
coi
nsur
ance
20
% c
oins
uran
ce
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
10
% c
oins
uran
ce
20%
coi
nsur
ance
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er s
pec
ial h
ealt
h
nee
ds
Hom
e he
alth
car
e 10
% c
oins
uran
ce
20%
coi
nsur
ance
50
vis
it lim
it *S
ee p
reau
thor
izat
ion
sche
dule
at
tach
ed to
you
r ce
rtifi
cate
of c
over
age.
Reh
abili
tatio
n se
rvic
es
10%
coi
nsur
ance
20
% c
oins
uran
ce
30 v
isit
limit
Hab
ilita
tion
serv
ices
10
% c
oins
uran
ce
20%
coi
nsur
ance
30
vis
it lim
it
Ski
lled
nurs
ing
care
10
% c
oins
uran
ce
20%
coi
nsur
ance
10
0 da
y lim
it
Dur
able
med
ical
equ
ipm
ent
10%
coi
nsur
ance
20
% c
oins
uran
ce
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
Hos
pice
ser
vice
s 10
% c
oins
uran
ce
20%
coi
nsur
ance
N
one
If y
ou
r ch
ild n
eed
s d
enta
l or
eye
care
--
Mo
re in
form
atio
n
abo
ut
par
tici
pat
ing
p
rovi
der
s an
d v
isio
n
care
ben
efit
s ar
e av
aila
ble
at
ww
w.d
avis
visi
on
.co
m
or
call
1-80
0-99
9-54
31.
Chi
ldre
n’s
eye
exam
N
o ch
arge
F
ull c
ost l
ess
$32
Lim
ited
to o
ne e
xam
per
yea
r
Chi
ldre
n’s
glas
ses
No
char
ge fo
r st
anda
rd
lens
es a
nd s
elec
t fr
ames
; Am
ount
ove
r $6
0 fo
r pr
ovid
er fr
ames
Ful
l cos
t les
s $5
5 fo
r st
anda
rd le
nses
and
any
fr
ame
Lim
ited
to o
ne p
air
of g
lass
es p
er y
ear
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
5 o
f 6
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/con
nect
/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s.)
Acu
punc
ture
Bar
iatr
ic S
urge
ry (
unle
ss m
edic
ally
nec
essa
ry)
Cos
met
ic S
urge
ry
Den
tal c
are
Hea
ring
aids
Long
-ter
m c
are
Rou
tine
foot
car
e (u
nles
s m
edic
ally
nec
essa
ry)
Wei
ght l
oss
prog
ram
s
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
Chi
ropr
actic
Car
e
Infe
rtili
ty tr
eatm
ent
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
.
Priv
ate-
duty
nur
sing
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if y
ou w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: 1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. Oth
er c
over
age
optio
ns m
ay b
e av
aila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l, or
a g
rieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
for
heal
th c
are
cove
rage
, con
tact
Cap
ital B
lue
Cro
ss a
t 1-8
00-2
16-9
741
or w
ww
.cap
blue
cros
s.co
m; f
or p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at
1-8
66-3
83-7
420
or w
ww
.exp
ress
-scr
ipts
.com
; for
men
tal/b
ehav
iora
l hea
lth o
r su
bsta
nce
abus
e, c
onta
ct In
tegr
ated
Beh
avio
ral H
ealth
at 1
-800
-395
-161
6 or
w
ww
.ibhc
orp.
com
; and
for
visi
on c
over
age,
con
tact
Dav
is V
isio
n at
1-8
00-9
99-5
431
or w
ww
.dav
isvi
sion
.com
. or
the
Dep
artm
ent o
f Lab
or’s
Em
ploy
ee B
enef
it S
ecur
ity
Adm
inis
trat
ion
at 1
-866
-444
-EB
SA
(32
72)
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm.
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge?
Y
es
If yo
u do
n’t h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th, y
ou’ll
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
. D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s?
Yes
If
your
pla
n do
esn’
t mee
t the
Min
imum
Val
ue S
tand
ards
, you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce.
Lan
gu
age
Acc
ess
Ser
vice
s:
[Spa
nish
(E
spañ
ol):
Par
a ob
tene
r as
iste
ncia
en
Esp
añol
, lla
me
al [i
nser
t tel
epho
ne n
umbe
r].]
[Tag
alog
(T
agal
og):
Kun
g ka
ilang
an n
inyo
ang
tulo
ng s
a T
agal
og tu
maw
ag
sa [i
nser
t tel
epho
ne n
umbe
r].]
[Chi
nese
(中文
): 如果需要中文的帮助,请拨打这个号码
[ins
ert t
elep
hone
num
ber]
.]
[Nav
ajo
(Din
e): D
inek
'ehg
o sh
ika
at'o
hwol
nin
isin
go, k
wiij
igo
holn
e' [i
nser
t tel
epho
ne n
umbe
r].]
––
––––
––––
––––
––––
––––
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n, s
ee th
e ne
xt s
ectio
n.––
––––
––––
––––
––––
––––
6 o
f 6
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in
-net
wor
k em
erge
ncy
room
vis
it an
d fo
llow
up
car
e)
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a
yea
r of
rou
tine
in-n
etw
ork
care
of a
wel
l-co
ntro
lled
cond
ition
)
T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
al (
faci
lity)
[co
st s
har
ing
] 10
%
O
ther
[co
st s
har
ing
] 10
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
h/D
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
h/D
eliv
ery
Fac
ility
Ser
vice
s D
iagn
ostic
test
s (u
ltras
ound
s an
d bl
ood
wor
k)
Spe
cial
ist v
isit
(ane
sthe
sia)
T
ota
l Exa
mp
le C
ost
$1
2,70
0 In
th
is e
xam
ple
, Peg
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$0
Cop
aym
ents
$5
0
Coi
nsur
ance
$1
,250
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
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T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
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faci
lity)
[co
st s
har
ing
] 10
%
O
ther
[co
st s
har
ing
] 10
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
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sts
(blo
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ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
)
To
tal E
xam
ple
Co
st
$7,4
00
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$0
Cop
aym
ents
$2
80
Coi
nsur
ance
$9
70
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$1,3
10
T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
al (
faci
lity)
[co
st s
har
ing
] 10
%
O
ther
[co
st s
har
ing
] 10
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
,900
In
th
is e
xam
ple
, Mia
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$0
Cop
aym
ents
$1
20
Coi
nsur
ance
$1
60
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$2
80
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
cost
s yo
u m
ight
pay
und
er d
iffer
ent h
ealth
pla
ns. P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e.
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
[01/
01/2
020
– 12
/31/
2020
] H
ealt
h M
ain
ten
ance
Org
aniz
atio
n (
HM
O):
Leh
igh
Un
iver
sity
C
ove
rag
e fo
r: In
divi
dual
and
Fam
ily |
Pla
n T
ype:
HM
O
Co
vera
ge
for:
___
____
____
__ |
Pla
n T
ype:
___
__
1 o
f 5
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es.
NO
TE
: In
form
atio
n a
bo
ut
the
cost
of
this
pla
n (
calle
d t
he
pre
miu
m)
will
be
pro
vid
ed s
epar
atel
y.
Th
is is
on
ly a
su
mm
ary.
For
mor
e in
form
atio
n ab
out y
our
cove
rage
, or
to g
et a
cop
y of
the
com
plet
e te
rms
of c
over
age:
abo
ut h
ealth
car
e co
vera
ge,
cont
act C
apita
l Blu
e C
ross
at 1
-800
-216
-974
1 or
ww
w.c
apbl
uecr
oss.
com
; abo
ut p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at 1
-866
-383
-742
0 or
w
ww
.exp
ress
-scr
ipts
.com
; abo
ut m
enta
l/beh
avio
ral h
ealth
or
subs
tanc
e ab
use,
con
tact
Inte
grat
ed B
ehav
iora
l Hea
lth a
t 1-8
00-3
95-1
616
or w
ww
.ibhc
orp.
com
; and
ab
out v
isio
n co
vera
ge, c
onta
ct D
avis
Vis
ion
at 1
-800
-999
-543
1 or
ww
w.d
avis
visi
on.c
om. F
or g
ener
al d
efin
ition
s of
com
mon
term
s, s
uch
as a
llow
ed a
mou
nt, b
alan
ce
billi
ng, c
oins
uran
ce, c
opay
men
t, de
duct
ible
, pro
vide
r, o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.c
ciio
.cm
s.go
v or
cal
l 1-8
88-
428-
2566
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
N
ot a
pplic
able
.
Thi
s pl
an d
oes
not h
ave
an o
vera
ll de
duct
ible
.
Are
th
ere
serv
ices
co
vere
d b
efo
re y
ou
mee
t yo
ur
ded
uct
ible
?
No.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t yet
met
the
dedu
ctib
le
amou
nt.
But
a c
opay
men
t or
coin
sura
nce
may
app
ly.
For
exa
mpl
e, th
is p
lan
cove
rs
cert
ain
prev
entiv
e se
rvic
es w
ithou
t cos
t-sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
. S
ee a
list
of c
over
ed p
reve
ntiv
e se
rvic
es a
t ht
tps:
//ww
w.h
ealth
care
.gov
/cov
erag
e/pr
even
tive
-car
e-be
nefit
s/.
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it f
or
this
pla
n?
$4,0
00 in
divi
dual
/ $8
,000
fam
ily c
ombi
ned
out-
of-p
ocke
t lim
it fo
r ne
twor
k m
edic
al a
nd
pres
crip
tion
drug
.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
Wh
at is
no
t in
clu
ded
in
the
ou
t-o
f-p
ock
et li
mit
?
Pre
miu
ms,
bal
ance
bill
ing
char
ges,
vis
ion
care
co
sts,
and
hea
lth c
are
this
pla
n do
esn'
t cov
er.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
war
d th
e ou
t-of
-poc
ket l
imit.
Will
yo
u p
ay le
ss if
yo
u
use
a n
etw
ork
pro
vid
er?
Yes
. For
a li
st o
f par
ticip
atin
g pr
ovid
ers,
see
w
ww
.cap
blue
cros
s.co
m o
r ca
ll 1-
800-
962-
2242
. Cal
l IB
H a
t 1-8
00-3
95-1
616
for
men
tal/b
ehav
iora
l hea
lth o
r su
bsta
nce
abus
e pr
ovid
ers.
See
ww
w.d
avis
visi
on.c
om o
r ca
ll 1-
800-
999-
5431
for
visi
on c
are
part
icip
atin
g pr
ovid
ers.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
's n
etw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd y
ou
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er's
cha
rge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
. B
e aw
are
your
net
wor
k pr
ovid
er m
ight
use
an
out
-of-
netw
ork
prov
ider
for
som
e se
rvic
es (
such
as
lab
wor
k).
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces.
Do
yo
u n
eed
a r
efer
ral t
o
see
a sp
ecia
list?
Y
es.
Thi
s pl
an w
ill p
ay s
ome
or a
ll of
the
cost
s to
see
a s
peci
alis
t for
cov
ered
ser
vice
s bu
t on
ly if
you
hav
e a
refe
rral
bef
ore
you
see
the
spec
ialis
t.
2 o
f 5
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/co
nnec
t/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
All
cop
aym
ent
and
coin
sura
nce
cos
ts s
how
n in
this
cha
rt a
re a
fter
your
ded
uct
ible
has
bee
n m
et, i
f a d
edu
ctib
le a
pplie
s.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
ca
re p
rovi
der
’s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry
or il
lnes
s $2
5 co
paym
ent/v
isit
Not
cov
ered
A
dditi
onal
$10
cop
aym
ent/v
isit
requ
ired
afte
r ho
urs.
Spe
cial
ist v
isit
$40
copa
ymen
t/vis
it N
ot c
over
ed
Non
e
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
N
ot c
over
ed
You
may
hav
e to
pay
for
serv
ices
that
are
n't
prev
entiv
e. A
sk y
our
prov
ider
if th
e se
rvic
es
you
need
are
pre
vent
ive.
The
n ch
eck
wha
t yo
ur p
lan
will
pay
for.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
wor
k)
No
char
ge fo
r la
b or
test
s N
ot c
over
ed
Non
e
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
N
o ch
arge
N
ot c
over
ed
*See
pre
auth
oriz
atio
n sc
hedu
le a
ttach
ed to
yo
ur c
ertif
icat
e of
cov
erag
e.
If y
ou
nee
d d
rug
s to
tr
eat
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on
dru
g
cove
rag
e is
ava
ilabl
e at
w
ww
.exp
ress
-sc
rip
ts.c
om
or
call
1-86
6-38
3-74
20.
Gen
eric
dru
gs
10%
coi
nsur
ance
(r
etai
l an
d m
ail o
rder
)
10%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Pre
ferr
ed b
rand
dru
gs
20%
coi
nsur
ance
(ret
ail a
nd m
ail o
rder
)
20%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Non
-pre
ferr
ed b
rand
dru
gs
30%
coi
nsur
ance
(r
etai
l and
mai
l ord
er)
30%
coi
nsur
ance
plu
s am
ount
ove
r E
xpre
ss
Scr
ipts
allo
wab
le
Cov
ers
30 to
90
day
supp
ly. S
ome
drug
s m
ay
requ
ire p
reau
thor
izat
ion.
If th
e ne
cess
ary
prea
utho
rizat
ion
is n
ot o
btai
ned,
the
drug
may
no
t be
cove
red.
Spe
cial
ty d
rugs
20%
coi
nsur
ance
for
pref
erre
d br
and
drug
s an
d 30
% c
oins
uran
ce
For
non
-pre
ferr
ed b
rand
dr
ugs
Not
cov
ered
S
ome
drug
s m
ay r
equi
re p
urch
ase
thro
ugh
Acc
redo
Spe
cial
ty P
harm
acy.
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
) N
o ch
arge
N
ot c
over
ed
Non
e
Phy
sici
an/s
urge
on fe
es
No
char
ge
Not
cov
ered
*S
ee p
reau
thor
izat
ion
sche
dule
atta
ched
to
your
cer
tific
ate
of c
over
age.
3 o
f 5
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/co
nnec
t/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er Im
po
rtan
t
Info
rmat
ion
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
00 c
opay
men
t/vis
it $1
00 c
opay
men
t/vis
it C
opay
men
t wai
ved
if ad
mitt
ed in
patie
nt.
Em
erge
ncy
med
ical
tran
spor
tatio
n N
o ch
arge
N
o ch
arge
N
one
Urg
ent c
are
$40
copa
ymen
t/vis
it N
ot c
over
ed
Non
e
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
$200
cop
aym
ent/s
ervi
ce
Not
cov
ered
*S
ee p
reau
thor
izat
ion
sche
dule
atta
ched
to
your
cer
tific
ate
of c
over
age.
Phy
sici
an/s
urge
on fe
es
No
char
ge
Not
cov
ered
N
one
If y
ou
nee
d m
enta
l h
ealt
h, b
ehav
iora
l h
ealt
h, o
r su
bst
ance
ab
use
ser
vice
s
Out
patie
nt s
ervi
ces
$25
copa
ymen
t/vis
it N
ot c
over
ed
Som
e se
rvic
es r
equi
re p
re-c
ertif
icat
ion.
Inpa
tient
ser
vice
s $2
00 c
opay
men
t/ser
vice
N
ot c
over
ed
Pre
-cer
tific
atio
n re
quire
d. 5
0% c
o-in
sura
nce
for
serv
ices
pro
vide
d w
ithou
t pre
-aut
horiz
atio
n.
If y
ou
are
pre
gn
ant
Offi
ce v
isits
$4
0 co
paym
ent/v
isit
Not
cov
ered
D
epen
ding
on
the
type
of s
ervi
ces,
a
copa
ymen
t, co
insu
ranc
e, o
r de
duct
ible
may
ap
ply.
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
se
rvic
es
No
char
ge
Not
cov
ered
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
N
o ch
arge
N
ot c
over
ed
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er s
pec
ial h
ealt
h
nee
ds
Hom
e he
alth
car
e N
o ch
arge
N
ot c
over
ed
100
visi
t lim
it *S
ee p
reau
thor
izat
ion
sche
dule
at
tach
ed to
you
r ce
rtifi
cate
of c
over
age.
Reh
abili
tatio
n se
rvic
es
No
char
ge
Not
cov
ered
30
vis
it lim
it
Hab
ilita
tion
serv
ices
N
o ch
arge
N
ot c
over
ed
30 v
isit
limit
Ski
lled
nurs
ing
care
N
o ch
arge
N
ot c
over
ed
60 d
ay li
mit.
Ski
lled
nurs
ing
limit
com
bine
d w
ith
acut
e in
patie
nt r
ehab
ilita
tion
limit.
Dur
able
med
ical
equ
ipm
ent
No
char
ge
Not
cov
ered
*S
ee p
reau
thor
izat
ion
sche
dule
atta
ched
to
your
cer
tific
ate
of c
over
age.
Hos
pice
ser
vice
s N
o ch
arge
N
ot c
over
ed
Non
e
If y
ou
r ch
ild n
eed
s d
enta
l or
eye
care
--
Mo
re in
form
atio
n
abo
ut
par
tici
pat
ing
p
rovi
der
s an
d v
isio
n
care
ben
efit
s ar
e av
aila
ble
at
ww
w.d
avis
visi
on
.co
m
or
call
1-80
0-99
9-54
31.
Chi
ldre
n’s
eye
exam
N
o ch
arge
F
ull c
ost l
ess
$32
Lim
ited
to o
ne e
xam
per
yea
r
Chi
ldre
n’s
glas
ses
No
char
ge fo
r st
anda
rd
lens
es a
nd s
elec
t fr
ames
; Am
ount
ove
r $6
0 fo
r pr
ovid
er fr
ames
Ful
l cos
t les
s $5
5 fo
r st
anda
rd le
nses
and
any
fr
ame
Lim
ited
to o
ne p
air
of g
lass
es p
er y
ear
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
4 o
f 5
*For
mor
e in
form
atio
n ab
out p
reau
thor
izat
ion,
see
ww
w.c
apbl
uecr
oss.
com
/wps
/wcm
/co
nnec
t/CB
C-P
ublic
/CB
C/M
embe
rs/P
reau
thor
izat
ion+
Req
uire
men
ts.
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s.)
Acu
punc
ture
Bar
iatr
ic S
urge
ry (
unle
ss m
edic
ally
nec
essa
ry)
Cos
met
ic S
urge
ry
Den
tal c
are
Hea
ring
aids
Long
-ter
m c
are
Rou
tine
foot
car
e (u
nles
s m
edic
ally
nec
essa
ry)
Wei
ght l
oss
prog
ram
s
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
Chi
ropr
actic
Car
e
Infe
rtili
ty tr
eatm
ent
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
.
Priv
ate-
duty
nur
sing
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: 1-8
66-4
44-E
BS
A (
3272
) or
ww
w.d
ol.g
ov/e
bsa/
heal
thre
form
. Oth
er c
over
age
optio
ns m
ay b
e av
aila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l, or
a g
rieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
for
heal
th c
are
cove
rage
, con
tact
Cap
ital B
lue
Cro
ss a
t 1-8
00-2
16-9
741
or w
ww
.cap
blue
cros
s.co
m; f
or p
resc
riptio
n dr
ug c
over
age,
con
tact
Exp
ress
Scr
ipts
at
1-8
66-3
83-7
420
or w
ww
.exp
ress
-scr
ipts
.com
; for
men
tal/b
ehav
iora
l hea
lth o
r su
bsta
nce
abus
e, c
onta
ct In
tegr
ated
Beh
avio
ral H
ealth
at 1
-800
-395
-161
6 or
w
ww
.ibhc
orp.
com
; and
for
visi
on c
over
age,
con
tact
Dav
is V
isio
n at
1-8
00-9
99-5
431
or w
ww
.dav
isvi
sion
.com
. or
the
Dep
artm
ent o
f Lab
or’s
Em
ploy
ee B
enef
it S
ecur
ity
Adm
inis
trat
ion
at 1
-866
-444
-EB
SA
(32
72)
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm.
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge?
Y
es
If yo
u do
n’t h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th, y
ou’ll
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
. D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s?
Yes
If
your
pla
n do
esn’
t mee
t the
Min
imum
Val
ue S
tand
ards
, you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce.
Lan
gu
age
Acc
ess
Ser
vice
s:
[Spa
nish
(E
spañ
ol):
Par
a ob
tene
r as
iste
ncia
en
Esp
añol
, lla
me
al [i
nser
t tel
epho
ne n
umbe
r].]
[Tag
alog
(T
agal
og):
Kun
g ka
ilang
an n
inyo
ang
tulo
ng s
a T
agal
og tu
maw
ag
sa [i
nser
t tel
epho
ne n
umbe
r].]
[Chi
nese
(中文
): 如果需要中文的帮助,请拨打这个号码
[ins
ert t
elep
hone
num
ber]
.]
[Nav
ajo
(Din
e): D
inek
'ehg
o sh
ika
at'o
hwol
nin
isin
go, k
wiij
igo
holn
e' [i
nser
t tel
epho
ne n
umbe
r].]
––
––––
––––
––––
––––
––––
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n, s
ee th
e ne
xt s
ectio
n.––
––––
––––
––––
––––
––––
5 o
f 5
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in
-net
wor
k em
erge
ncy
room
vis
it an
d fo
llow
up
car
e)
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a
yea
r of
rou
tine
in-n
etw
ork
care
of a
wel
l-co
ntro
lled
cond
ition
)
T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
al (
faci
lity)
[co
st s
har
ing
] 0%
Oth
er [
cost
sh
arin
g]
0%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
h/D
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
h/D
eliv
ery
Fac
ility
Ser
vice
s D
iagn
ostic
test
s (u
ltras
ound
s an
d bl
ood
wor
k)
Spe
cial
ist v
isit
(ane
sthe
sia)
T
ota
l Exa
mp
le C
ost
$1
2,70
0 In
th
is e
xam
ple
, Peg
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$
Cop
aym
ents
$2
50
Coi
nsur
ance
$0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
10
T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
al (
faci
lity)
[co
st s
har
ing
] 0%
Oth
er [
cost
sh
arin
g]
0%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
)
To
tal E
xam
ple
Co
st
$7,4
00
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$0
Cop
aym
ents
$2
80
Coi
nsur
ance
$7
80
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$1,1
20
T
he
pla
n’s
ove
rall
ded
uct
ible
$0
Sp
ecia
list
[co
st s
har
ing
] $4
0
Ho
spit
al (
faci
lity)
[co
st s
har
ing
] 0%
Oth
er [
cost
sh
arin
g]
0%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
,900
In
th
is e
xam
ple
, Mia
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$0
Cop
aym
ents
$1
20
Coi
nsur
ance
$0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
20
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
cost
s yo
u m
ight
pay
und
er d
iffer
ent h
ealth
pla
ns. P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e.
Plan Design DetailsAppendix 2
PPQSK008.009 Large Group – QHDHP PPO Plan 01/2020 1/1/2020
Document Assistant Ask Alexa “Open my Cap
BlueCross” and follow instructions
BENEFIT HIGHLIGHTS
HDHP PPO PLAN
Lehigh University
This information is not a contract, but highlights some of the benefits available to you and is not intended to be a complete list or description of available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (also known as “benefit booklet”). Refer to your benefit booklet for complete details.
YOUR MEDICAL PLAN SUMMARY OF COST SHARING Member Responsibilities
If provider is participating If provider is nonparticipating Deductible (per benefit period) Deductible is combined to include medical and prescription drug benefits for participating providers. If you enroll in a family plan, the overall family deductible must be met before the plan begins to pay.
$1,400 per member $2,800 per family
$2,500 per member
$5,000 per family
Coinsurance (percentage you pay after your deductible is met) 20% coinsurance 30% coinsurance Out-of-Pocket Maximum (The most you pay per benefit period, after which benefits are paid at 100%. This includes deductible, copayments and coinsurance for medical including ER and prescription drug for participating providers only.)
$6,900 per member $13,800 per family
Unlimited
Office Visit / Urgent Care / Emergency Room Copayments Virtual Visits (performed through our Virtual Care tool) $10 copayment per visit after
deductible Not covered
Office Visits (performed by a family practitioner, general practitioner, internist, pediatrician or participating retail clinic)
20% coinsurance after deductible 30% coinsurance after deductible
Specialist Office Visits 20% coinsurance after deductible 30% coinsurance after deductible Urgent Care Services 20% coinsurance after deductible 30% coinsurance after deductible Emergency Room 20% coinsurance after deductible
Preventive Care Pediatric and Adult Preventive Care No charge, waive deductible Not covered Screening Gynecological Exam and Pap Smear (one per benefit period)
No charge, waive deductible 30% coinsurance, waive deductible
Screening Mammogram (one per benefit period) No charge, waive deductible 30% coinsurance, waive deductible Diagnostic Mammogram 20% coinsurance after deductible 30% coinsurance after deductible
Facility / Surgical Services Inpatient Hospital Room and Board 20% coinsurance after deductible 30% coinsurance after deductible Acute Inpatient Rehabilitation (60 days per benefit period) 20% coinsurance after deductible 30% coinsurance after deductible Skilled Nursing Facility (120 days per benefit period) 20% coinsurance after deductible 30% coinsurance after deductible Maternity Services and Newborn Care 20% coinsurance after deductible 30% coinsurance after deductible Surgical Procedure and Anesthesia (professional charges) 20% coinsurance after deductible 30% coinsurance after deductible
Outpatient Surgery at Ambulatory Surgical Center (facility charge only)
20% coinsurance after deductible Not covered
Outpatient Surgery at Acute Care Hospital (facility charge only) 20% coinsurance after deductible 30% coinsurance after deductible
Diagnostic Services
High Tech Imaging (such as MRI, CT, PET) 20% coinsurance after deductible 30% coinsurance after deductible
Radiology (other than high tech imaging) 20% coinsurance after deductible 30% coinsurance after deductible Independent Laboratory 20% coinsurance after deductible 30% coinsurance after deductible
Facility-owned Laboratory (i.e. Health System owned) 20% coinsurance after deductible 30% coinsurance after deductible
Therapy Services (Rehabilitative and Habilitative Services) Physical Therapy 20% coinsurance after deductible 30% coinsurance after deductible Occupational Therapy 20% coinsurance after deductible 30% coinsurance after deductible Speech Therapy 20% coinsurance after deductible 30% coinsurance after deductible Respiratory Therapy 20% coinsurance after deductible 30% coinsurance after deductible Manipulation Therapy 20% coinsurance after deductible 30% coinsurance after deductible
Mental Health (MH) and Substance Use Disorder Services (SUD) MH Inpatient Services 20% coinsurance after deductible 30% coinsurance after deductible MH Outpatient Services 20% coinsurance after deductible 30% coinsurance after deductible SUD Detoxification Inpatient 20% coinsurance after deductible 30% coinsurance after deductible SUD Rehabilitation Outpatient 20% coinsurance after deductible 30% coinsurance after deductible
Additional Services Home Health Care Services (90 visits per benefit period) 20% coinsurance after deductible 30% coinsurance after deductible Durable Medical Equipment and Supplies 20% coinsurance after deductible 30% coinsurance after deductible Prosthetic Appliances 20% coinsurance after deductible 30% coinsurance after deductible Orthotic Devices 20% coinsurance after deductible 30% coinsurance after deductible
Benefits are underwritten by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. An independent licensee of the BlueCross BlueShield Association.
www.capbluecross.com
PPQSK008.009 Large Group – QHDHP PPO Plan 01/2020 1/1/2020
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits coverage you may have.
Participating providers agree to accept our allowance as payment in full—often less than their normal charge. If you visit a nonparticipating provide, you are responsible for paying the deductible, coinsurance and the difference between the nonparticipating provider’s charges and the allowed amount. Nonparticipating Providers may balance bill the member. Some nonparticipating facility providers are not covered. In certain situations, a facility fee may be associated with an outpatient visit to a professional provider. Members should consult with the provider of the services to determine whether a facility fee may apply to that provider. An additional cost sharing amount may apply to the facility fee.
Voice activated paper.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
PPOSK006 Large Group – PPO Plan 01/2020 1/1/2020
Document Assistant Ask Alexa “Open my Cap
BlueCross” and follow instructions
BENEFIT HIGHLIGHTS
PPO Plan
Lehigh University
This information is not a contract, but highlights some of the benefits available to you and is not intended to be a complete list or description of available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (also known as “benefit booklet”). Refer to your benefit booklet for complete details.
YOUR MEDICAL PLAN SUMMARY OF COST SHARING Member Responsibilities
If provider is participating If provider is nonparticipating
Deductible (per benefit period) $200 per member $600 per family
$500 per member
Coinsurance (percentage you pay after your deductible is met) 20% coinsurance 30% coinsurance Out-of-Pocket Maximum (The most you pay per benefit period, after which benefits are paid at 100%. This includes deductible, copayments and coinsurance for medical including ER and prescription drug, for participating providers only.)
$4,000 per member $8,000 per family
Unlimited
Office Visit / Urgent Care / Emergency Room Copayments Virtual Visits (performed through our Virtual Care tool)
$10 copayment per visit Not covered
Office Visits (performed by a family practitioner, general practitioner, internist, pediatrician or participating retail clinic)
$25 copayment per visit 30% coinsurance after deductible
Specialist Office Visits $40 copayment per visit 30% coinsurance after deductible Urgent Care Services $40 copayment per visit 30% coinsurance after deductible Emergency Room $100 copayment per visit, waived if admitted
Preventive Care Pediatric and Adult Preventive Care No charge, waive deductible Not covered Screening Gynecological Exam and Pap Smear (one per benefit period)
No charge, waive deductible 30% coinsurance, waive deductible
Screening Mammogram (one per benefit period) No charge, waive deductible 30% coinsurance, waive deductible Diagnostic Mammogram 20% coinsurance after deductible 30% coinsurance after deductible
Facility / Surgical Services Inpatient Hospital Room and Board 20% coinsurance after deductible 30% coinsurance after deductible Acute Inpatient Rehabilitation 20% coinsurance after deductible 30% coinsurance after deductible Skilled Nursing Facility (100 days per benefit period) 20% coinsurance after deductible 30% coinsurance after deductible Maternity Services and Newborn Care (professional charges) 20% coinsurance after deductible 30% coinsurance after deductible Surgical Procedure and Anesthesia (professional charges) 20% coinsurance after deductible 30% coinsurance after deductible
Outpatient Surgery at Ambulatory Surgical Center (facility charge only)
20% coinsurance after deductible 30% coinsurance after deductible
Outpatient Surgery at Acute Care Hospital (facility charge only) 20% coinsurance after deductible 30% coinsurance after deductible
Diagnostic Services
High Tech Imaging (such as MRI, CT, PET) 20% coinsurance after deductible 30% coinsurance after deductible
Radiology (other than high tech imaging) 20% coinsurance after deductible 30% coinsurance after deductible Independent Laboratory 20% coinsurance after deductible 30% coinsurance after deductible
Facility-owned Laboratory (i.e. Health System owned) 20% coinsurance after deductible 30% coinsurance after deductible
Therapy Services (Rehabilitative and Habilitative Services) Physical Therapy 20% coinsurance after deductible 30% coinsurance after deductible Occupational Therapy 20% coinsurance after deductible 30% coinsurance after deductible Speech Therapy 20% coinsurance after deductible 30% coinsurance after deductible Respiratory Therapy 20% coinsurance after deductible 30% coinsurance after deductible Manipulation Therapy ( 20% coinsurance after deductible 30% coinsurance after deductible
Mental Health (MH) and Substance Use Disorder Services (SUD) MH Inpatient Services 20% coinsurance after deductible 30% coinsurance after deductible MH Outpatient Services $25 copayment per visit 30% coinsurance after deductible SUD Detoxification Inpatient 20% coinsurance after deductible 30% coinsurance after deductible SUD Rehabilitation Outpatient $25 copayment per visit 30% coinsurance after deductible
Additional Services Home Health Care Services (90 visits per benefit period) 20% coinsurance after deductible 30% coinsurance after deductible Durable Medical Equipment and Supplies 20% coinsurance after deductible 30% coinsurance after deductible Prosthetic Appliances 20% coinsurance after deductible 30% coinsurance after deductible Orthotic Devices 20% coinsurance after deductible 30% coinsurance after deductible
Benefits are underwritten by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. An independent licensee of the BlueCross BlueShield Association.
www.capbluecross.com
PPOSK006 Large Group – PPO Plan 01/2020 1/1/2020
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits coverage you may have.
Participating providers agree to accept our allowance as payment in full—often less than their normal charge. If you visit a nonparticipating provider, you are responsible for paying the deductible, coinsurance and the difference between the nonparticipating provider’ charges and the allowed amount. Nonparticipating Providers may balance bill the member. Some nonparticipating facility providers are not covered. In certain situations, a facility fee may be associated with an outpatient visit to a professional provider. Members should consult with the provider of the services to determine whether a facility fee may apply to that provider. An additional cost sharing amount may apply to the facility fee.
Voice activated paper.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
PPOSK007 Large Group – PPO Plan 01/2020 1/1/2020
Document Assistant Ask Alexa “Open my Cap
BlueCross” and follow instructions
BENEFIT HIGHLIGHTS
PPO Plus Plan
Lehigh University
This information is not a contract, but highlights some of the benefits available to you and is not intended to be a complete list or description of available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (also known as “benefit booklet”). Refer to your benefit booklet for complete details.
YOUR MEDICAL PLAN SUMMARY OF COST SHARING Member Responsibilities
If provider is participating If provider is nonparticipating
Deductible (per benefit period) Not Applicable $500 per member
Coinsurance (percentage you pay after your deductible is met) 10% coinsurance 20% coinsurance Out-of-Pocket Maximum (The most you pay per benefit period, after which benefits are paid at 100%. This includes deductible, copayments and coinsurance for medical including ER and prescription drug, for participating providers only.)
$4,000 per member $8,000 per family
Unlimited
Office Visit / Urgent Care / Emergency Room Copayments Virtual Visits (performed through our Virtual Care tool)
$10 copayment per visit Not covered
Office Visits (performed by a family practitioner, general practitioner, internist, pediatrician or participating retail clinic)
$25 copayment per visit 20% coinsurance after deductible
Specialist Office Visits $40 copayment per visit 20% coinsurance after deductible Urgent Care Services $40 copayment per visit 20% coinsurance after deductible Emergency Room $100 copayment per visit, waived if admitted
Preventive Care Pediatric and Adult Preventive Care No charge Not covered Screening Gynecological Exam and Pap Smear (one per benefit period)
No charge 20% coinsurance, waive deductible
Screening Mammogram (one per benefit period) No charge 20% coinsurance, waive deductible Diagnostic Mammogram 10% coinsurance 20% coinsurance after deductible
Facility / Surgical Services Inpatient Hospital Room and Board 10% coinsurance 20% coinsurance after deductible Acute Inpatient Rehabilitation 10% coinsurance 20% coinsurance after deductible Skilled Nursing Facility (120 days per benefit period) 10% coinsurance 20% coinsurance after deductible Maternity Services and Newborn Care (professional charges) 10% coinsurance 20% coinsurance after deductible Surgical Procedure and Anesthesia (professional charges) 10% coinsurance 20% coinsurance after deductible
Outpatient Surgery at Ambulatory Surgical Center (facility charge only)
10% coinsurance 20% coinsurance after deductible
Outpatient Surgery at Acute Care Hospital (facility charge only) 10% coinsurance 20% coinsurance after deductible
Diagnostic Services
High Tech Imaging (such as MRI, CT, PET) 10% coinsurance 20% coinsurance after deductible
Radiology (other than high tech imaging) 10% coinsurance 20% coinsurance after deductible Independent Laboratory 10% coinsurance 20% coinsurance after deductible
Facility-owned Laboratory (i.e. Health System owned) 10% coinsurance 20% coinsurance after deductible
Therapy Services (Rehabilitative and Habilitative Services) Physical Therapy (30 visits per benefit period per condition) 10% coinsurance 20% coinsurance after deductible Occupational Therapy (30 visits per benefit period) 10% coinsurance 20% coinsurance after deductible Speech Therapy (30 visits per benefit period) 10% coinsurance 20% coinsurance after deductible Respiratory Therapy 10% coinsurance 20% coinsurance after deductible Manipulation Therapy 10% coinsurance 20% coinsurance after deductible
Mental Health (MH) and Substance Use Disorder Services (SUD) MH Inpatient Services
COVERAGE PROVIDED UNDER A SEPARATE BEHAVORIAL HEALTH PROGRAM OFFERED BY LEHIGH UNIVERSITY
MH Outpatient Services SUD Detoxification Inpatient SUD Rehabilitation Outpatient
Additional Services Home Health Care Services (90 visits per benefit period) 10% coinsurance 20% coinsurance after deductible Durable Medical Equipment and Supplies 10% coinsurance 20% coinsurance after deductible Prosthetic Appliances 10% coinsurance 20% coinsurance after deductible Orthotic Devices 10% coinsurance 20% coinsurance after deductible
Benefits are underwritten by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. An independent licensee of the BlueCross BlueShield Association.
www.capbluecross.com
PPOSK007 Large Group – PPO Plan 01/2020 1/1/2020
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits coverage you may have.
Participating providers agree to accept our allowance as payment in full—often less than their normal charge. If you visit a nonparticipating provider, you are responsible for paying the deductible, coinsurance and the difference between the nonparticipating provider’ charges and the allowed amount. Nonparticipating Providers may balance bill the member. Some nonparticipating facility providers are not covered. In certain situations, a facility fee may be associated with an outpatient visit to a professional provider. Members should consult with the provider of the services to determine whether a facility fee may apply to that provider. An additional cost sharing amount may apply to the facility fee.
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Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
HMOSK005 Large Group – HMO Plan 01/2020 1/1/2020
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BENEFIT HIGHLIGHTS
HMO PLAN
Lehigh University
This information is not a contract, but highlights some of the benefits available to you and is not intended to be a complete list or description of available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (also known as “benefit booklet”). Refer to your benefit booklet for complete details.
YOUR MEDICAL PLAN SUMMARY OF COST SHARING Member Responsibilities
Deductible (per benefit period) Deductible is combine to include medical and prescription drug benefits for participating providers.
Not Applicable
Coinsurance (percentage you pay after your deductible is met) No member coinsurance Out-of-Pocket Maximum (The most you pay per benefit period, after which benefits are paid at 100%. This includes deductible, copayments and coinsurance for medical including ER, prescription drug, pediatric dental, and pediatric vision for participating providers only.)
$4,000 per member $8,000 per family
Office Visit / Urgent Care / Emergency Room Copayments Virtual Visits (performed through our Virtual Care tool)
$10 copayment per visit
Office Visits (performed by a family practitioner, general practitioner, internist, pediatrician or participating retail clinic)
$25 copayment per visit
Specialist Office Visits $40 copayment per visit Urgent Care Services $40 copayment per visit Emergency Room $100 copayment per visit, waived if admitted
Preventive Care Pediatric and Adult Preventive Care No charge Screening Gynecological Exam and Pap Smear (one per benefit period) No charge (no referral necessary) Screening Mammogram (one per benefit period) No charge (no referral necessary) Diagnostic Mammogram (one per benefit period) No charge
Facility / Surgical Services Inpatient Hospital Room and Board $200 copayment per admission Acute Inpatient Rehabilitation (60 days per benefit period combined) Skilled Nursing Facility
$200 copayment per admission
Maternity Services and Newborn Care $200 copayment per admission Surgical Procedure and Anesthesia (professional charges) No charge
Outpatient Surgery at Ambulatory Surgical Center (facility charge only) No charge Outpatient Surgery at Acute Care Hospital (facility charge only) No charge
Diagnostic Services
High Tech Imaging (such as MRI, CT, PET) No charge
Radiology (other than high tech imaging) No charge Independent Laboratory No charge
Facility-owned Laboratory (i.e. Health System owned) No charge
Therapy Services (Rehabilitative and Habilitative Services) Physical Therapy (30 visits per benefit period) No charge Occupational Therapy (30 visits per benefit period) No charge Speech Therapy (rehabilitative and habilitative, 30 visits each per benefit period) No charge Respiratory/Pulmonary Therapy (30 rehabilitative visits per benefit period) No charge Manipulation Therapy (30 visits per benefit period) No charge
Mental Health (MH) and Substance Use Disorder Services (SUD) MH Inpatient Services
COVERAGE PROVIDED UNDER A SEPARATE BEHAVORIAL HEALTH PROGRAM OFFERED BY LEHIGH UNIVERSITY
MH Outpatient Services SUD Detoxification Inpatient SUD Rehabilitation Outpatient
Additional Services Home Health Care Services (100 visits per benefit period) No charge Durable Medical Equipment and Supplies No charge Prosthetic Appliances No charge Orthotic Devices No charge
Benefits are underwritten by Keystone Health Plan® Central, a subsidiary of Capital BlueCross. Independent licensee of the Blue Cross and Blue Shield Association.
www.capbluecross.com
HMOSK005 Large Group – HMO Plan 01/2020 1/1/2020
All services must be received from Participating Providers within Keystone’s Approved Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (2) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s approved Service Area.
*Certain preventive contraceptives are required to be covered at no cost to you when filled at a participating pharmacy with a valid prescription in accordance with Preventive Health Guidelines.
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Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
Preauthorization Program Effective Date: 01/01/2020
For Commercial Medical Benefits
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
CBC-Preauth-123 (01/01/20) 1
SERVICES REQUIRING PREAUTHORIZATION
Members should present their identification card to their health care provider when medical services or items are requested. When members use a participating provider (including a BlueCard facility participating provider providing inpatient services), the participating provider will be responsible for obtaining the preauthorization. If members use a non-participating provider or a BlueCard participating provider providing non-inpatient services, the non-participating provider or BlueCard participating provider may call for preauthorization on the member’s behalf; however, it is ultimately the member’s responsibility to obtain preauthorization. Providers and members should call Capital’s Utilization Management Department toll-free at 1-800-730-7219 to obtain the necessary preauthorization.
Providers/Members should request Preauthorization of non-urgent admissions and services well in advance of the scheduled date of service (15 days). Investigational or experimental procedures are not usually covered benefits. Members should consult their Certificate of Coverage or Contract, Capital BlueCross’ Medical Policies, or contact Customer Service at the number listed on the back of their health plan identification card to confirm coverage. Participating providers and members have full access to Capital’s medical policies and may request preauthorization for experimental or investigational services/items if there are unique member circumstances.
Capital only pays for services and items that are considered medically necessary. Providers and members can reference Capital’s medical policies for questions regarding medical necessity. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.
PREAUTHORIZATION OF MEDICAL SERVICES INVOLVING URGENT CARE
If the member’s request for preauthorization involves urgent care, the member or the member’s provider should advise Capital of the urgent medical circumstances when the member or the member’s provider submits the request to Capital’s Clinical Management Department. Capital will respond to the member and the member’s provider no later than seventy-two (72) hours after Capital’s Utilization Management Department receives the preauthorization request.
FAILURE TO OBTAIN PREAUTHORIZATION
Failure to obtain preauthorization for a service could result in a payment reduction or denial for the provider and benefit reduction or denial for the member, based on the provider’s contract and the member’s Certificate of Coverage or Contract. Services or items provided without preauthorization may also be subject to retrospective medical necessity review.
If the member presents his/her ID card to a participating provider in the 21-county area and the participating provider fails to obtain or follow preauthorization requirements, payment for services will be denied and the provider may not bill the member.
The table that follows is a partial listing of the preauthorization requirements for services and procedures.
The attached list provides categories of services for which preauthorization is required, as well as specific examples of such services. This list is not all inclusive. Capital may from time to time remove preauthorization requirements for benefits under certain dollar thresholds. For a listing of services currently requiring preauthorization, including any threshold requirements,
members and providers may consult capbluecross.com.
Preauthorization Program Effective Date: 01/01/2020
For Commercial Medical Benefits
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
CBC-Preauth-123 (01/01/20) 2
Category Details Comments
Inpatient Admissions
Acute care
Long-term acute care
Non-routine maternity admissions and newborns requiring continued hospitalization after the mother is discharged
Skilled nursing facilities
Rehabilitation hospitals
Behavioral Health (mental health care/ substance use disorder)
Preauthorization requirements do not apply to services provided by a hospital emergency room provider. If an inpatient admission results from an emergency room visit, notification must occur within two (2) business days of the admission. All such services will be reviewed and must meet medical necessity criteria from the first hour of admission. Failure to notify Capital of an admission may result in an administrative denial. Non-routine maternity admissions, including preterm labor and maternity complications, require notification within two (2) business days of the date of admission.
Observation Care Admissions
Notification is required for all observation stays expected to exceed 48 hours.
All observation care must meet medical necessity criteria from the first hour of admission.
Admissions to observation status require notification within two (2) business days. Failure to notify Capital of an admission may result in an administrative denial.
Diagnostic Services
Genetic disorder testing except: standard chromosomal tests, such as Down Syndrome, Trisomy, and Fragile X, and state mandated newborn genetic testing.
High tech imaging such as but not limited to: Cardiac nuclear medicine studies including nuclear cardiac stress tests, CT (computerized tomography) scans, MRA (magnetic resonance angiography), MRI (magnetic resonance imaging), PET (positron emission tomography) scans, and SPECT (single proton emission computerized tomography) scans.
Diagnostic services do not require preauthorization when emergently performed during an emergency room visit, observation stay, or inpatient admission.
Durable Medical Equipment (DME), Prosthetic, Appliances, Orthotic Devices, Implants
Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Preauthorization Program Effective Date: 01/01/2020
For Commercial Medical Benefits
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
CBC-Preauth-123 (01/01/20) 3
Category Details Comments
Office Surgical Procedures When Performed in a Facility*
Aspiration and/or injection of a joint
Colposcopy
Treatment of warts
Excision of a cyst of the eyelid (chalazion)
Excision of a nail (partial or complete)
Excision of external thrombosed hemorrhoids;
Injection of a ligament or tendon;
Eye injections (intraocular)
Oral Surgery
Pain management (including trigger point injections, stellate ganglion blocks, peripheral nerve blocks, and intercostal nerve blocks)
Proctosigmoidoscopy/flexible Sigmoidoscopy;
Removal of partial or complete bony impacted teeth (if a benefit);
Repair of lacerations, including suturing (2.5 cm or less);
Vasectomy
Wound care and dressings (including outpatient burn care)
The items listed are examples of services considered safe to perform in a professional provider’s office. Medical necessity review is required when office procedures are performed in a facility setting. Members and providers may view a listing of services currently requiring preauthorization when performed in a facility at capbluecross.com.
Outpatient Procedures/ Surgery
Weight loss surgery (Bariatric)
Meniscal transplants, allografts and collagen meniscus implants (knee)
Ovarian and Iliac Vein Embolization
Photodynamic therapy
Radioembolization for primary and metastatic tumors of the liver
Radiofrequency ablation of tumors
Transcatheter aortic valve replacement
Valvuloplasty
The items listed are examples of outpatient procedures that may be reviewed for medical necessity and or place of service. Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Therapy Services Hyperbaric oxygen therapy (non-emergency)
Occupational therapy
Physical therapy
Pulmonary rehabilitation programs
Transplant Surgeries
Evaluation and services related to transplants Preauthorization will include referral assistance to the Blue Distinction Centers for Transplant network if appropriate.
Preauthorization Program Effective Date: 01/01/2020
For Commercial Medical Benefits
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
CBC-Preauth-123 (01/01/20) 4
Category Details Comments
Reconstructive or Cosmetic Services and Items
Removal of excess fat tissue (Abdominoplasty/Panniculectomy and other removal of fat tissue such as Suction Assisted Lipectomy)
Breast Procedures Breast Enhancement (Augmentation) Breast Reduction Mastectomy (Breast removal or reduction) for
Gynecomastia Breast Lift (Mastopexy) Removal of Breast implants
Correction of protruding ears (Otoplasty)
Repair of nasal/septal defects (Rhinoplasty/Septoplasty)
Skin related procedures Acne surgery Dermabrasion Hair removal (Electrolysis/Epilation) Face Lift (Rhytidectomy) Removal of excess tissue around the eyes
(Blepharoplasty/Brow Ptosis Repair) Mohs Surgery when performed on two separate
dates of service by the same provider
Treatment of Varicose Veins and Venous Insufficiency
Medical Injectables Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Investigational and Experimental procedures, devices, therapies, and pharmaceuticals
Investigational or experimental procedures are not usually covered benefits. Members and providers may request preauthorization for experimental or investigational services/items if there are unique member circumstances.
New to market procedures, devices, therapies, and pharmaceuticals
Preauthorization is required during the first two (2) years after a procedure, device, therapy or pharmaceutical enters the market. Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Select Outpatient Behavioral Health Services
Transcranial Magnetic Stimulation (TMS)
Partial Hospitalization
Substance Use Disorder Intensive Outpatient Programs
The items listed are examples of outpatient procedures that may be reviewed for medical necessity and or place of service. Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Preauthorization Program Effective Date: 01/01/2020
For Commercial Medical Benefits
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its
capacity as administrator of programs and provider relations for all companies.
CBC-Preauth-123 (01/01/20) 5
Category Details Comments
Other Services Bio-engineered skin or biological wound care products
Category IDE trials (Investigational Device Exemption)
Clinical trials (including cancer related trials)
Enhanced external counterpulsation (EECP)
Home health care
Home infusion therapy
Eye injections (Intravitreal angiogenesis inhibitors)
Laser treatment of skin lesions
Non-emergency air and ground ambulance transports
Radiofrequency ablation for pain management
Facility based sleep studies for diagnosis and medical Management of obstructive sleep apnea
Enteral feeding supplies and services
Pain Management Interventional Pain Management
Joint injections
Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Oncology Services Radiation therapy and related treatment planning and procedures performed for planning (such as but not limited to IMRT, proton beam, neutron beam, brachytherapy, 3D conform, SRS, SBRT, gamma knife, EBRT, IORT, IGRT, and hyperthermia treatments.)
Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
Select Cardiac Services
Members and providers may view a listing of services currently requiring preauthorization at capbluecross.com.
PLEASE NOTE: This listing identifies those services that require preauthorization only as of the date it was printed. This listing is subject to change. Members should call Capital at 1-800-730-7219 (TTY: 711) with questions regarding the preauthorization of a particular service.
For HMO and Gatekeeper PPO members, all care rendered by non participating providers requires preauthorization. This includes care that falls under the Continuity of Care provision of the Certificate of Coverage or Contract.
This information highlights the standard Preauthorization Program. Members should refer to their Certificate of Coverage or Contract for the specific terms, conditions, exclusions and limitations relating to their coverage.
Managed Behavioral Health in PPO Plus and Keystone Plans Lehigh University Benefit Plan Summary for Keystone Health Plan 2020
Service IBH Network Non-Network
Pre-Certification
Inpatient Psychiatric Care Out of pocket network only
100%, after $200 copay per admission. Individual $4,000 Family $8,000
No benefit Required through IBH
Mental Health (MH)- Outpatient Office Visits –Individual, Family, Group Counseling Out of pocket network only
$25 co-pay Individual $4,000 Family $8,000
No benefit Some services require Pre-Certification.
Inpatient Chemical Dependence (CD)/Substance Abuse Out of pocket network only
100%, after $200 copay per admission. Individual $4,000 Family $8,000
No benefit Required through IBH
Chemical Dependence (CD)/Substance Abuse - Outpatient Office Visits –Individual, Family, Group Counseling Out of pocket network only
$25 co-pay Individual $4,000 Family $8,000
No benefit Some services require Pre-Certification.
• Only inpatient services pre-certified by IBH and provided by network providers are covered. There is no benefit for non-networkproviders or for services not pre-certified.
• Treatment must be provided by a psychiatrist, psychologist, therapist or clinical social worker who is licensed to practice independently atthe master’s level or above.
• Laboratory work must be prescribed by a psychiatrist.• Treatment must be delivered in a goal-oriented manner that produces observable and measurable improvement in the patient’s condition.• Autism disorder treatment up to the 2020 cap permitted by Pennsylvania Act 62.
Lehigh University Benefit Plan Summary for PPO Plus 2020 Service IBH Network Non-Network Pre-Certification
Inpatient Psychiatric Care Out of pocket network only
IBH pays 90% of allowable charges. Individual $4,000 Family $8,000
80% of IBH allowable after $500 deductible (combined MH, CD, and medical)
Required through IBH for both network and non-network 50% penalty for services provided by non-network providers w/o pre-authorization
Mental Health (MH)- Outpatient Office Visits –Individual, Family, Group Counseling Out of pocket network only
$25 co-pay Individual $4,000 Family $8,000
80% of IBH allowable after $500 deductible (combined MH, CD, and medical)
Some services require Pre-Certification.
Inpatient Chemical Dependence (CD)/Substance Abuse Out of pocket network only
IBH pays 90% of allowable charges Individual $4,000 Family $8,000
80% of IBH allowable after $500 deductible (combined MH, CD, and medical)) .
Required through IBH for both network and non-network 50% penalty for services provided by non-network providers w/o pre-authorization
Chemical Dependence (CD)/ Substance Abuse - Outpatient Office Visits –Individual, Family, Group Counseling Out of pocket network only
$25 co-pay Individual $4,000 Family $8,000
80% of IBH allowable after $500 deductible (combined MH, CD, and medical)
Some services require Pre-Certification.
• Treatment must be provided by a psychiatrist, psychologist, therapist or clinical social worker who is licensed to practice independently atthe master’s level or above.
• Laboratory work must be prescribed by a psychiatrist.• Treatment must be delivered in a goal-oriented manner that produces observable and measurable improvement in the patient’s condition.• Autism disorder treatment up to the 2020 cap permitted by Pennsylvania Act 62.
A Managed Behavioral Health Plan includes mental health and substance abuse treatment benefits. The behavioral health benefit included for this plan is provided by Integrated Behavioral Health (IBH). This plan is compliant with the Mental Health Parity and Equity Act of 2008 (MHPAEA) and Final Rules of 2013.
Plan features include: • Use of IBH network providers results in lower copays, coinsurance and patient financial
responsibility.• National network of quality providers and facilities selected and credentialed by IBH.• No need for patient submission of claim forms when IBH network providers are used.• IBH network providers accept the plan payment as payment in full after the applicable
copayment or deductible.• All mental health services are subject to evidentiary standards of care and medical
necessity.• Some services require prior authorization, call IBH for care coordination.• If treatment is needed call 800-‐395-‐1616 and IBH will provide referrals, case
management, care coordination, and benefit questions for your behavioral health plan.
Certain services are still required to be pre-‐authorized; contact IBH with any questions.
Pre-‐authorization of all behavioral health services including initial outpatient care with a psychiatrist, psychologist or therapist is highly recommended. Pre-‐authorization of behavioral health services will insure medical necessity criteria are met and retrospective review will be limited. All care is subject to eligibility, plan definitions, limitations, exclusions, and are payable when determined by IBH as medically necessary and appropriate.
Inpatient and Program based Mental Health Benefits: To find an in-‐network facility, contact Integrated Behavioral Health at 800-‐395-‐1616. The benefit may allow you to choose services through an out-‐of-‐network facility, but you may have to pay a larger portion of the costs, and subject to prior authorization and concurrent review.
Pre-‐authorization is required for all inpatient, partial hospitalization, residential, and any program based care. You or your provider may call an IBH care manager at 800-‐395-‐1616 to obtain preauthorization prior to starting any intensive treatment program.
Outpatient Mental Health Benefits: All outpatient care falling within outlier categories, requires the provider to submit documentation for review of medical necessity, evidentiary based treatment, and appropriateness of care.
The following outpatient evaluations or treatments require authorization before commencing: • Psychological testing• Group therapy
• Outpatient Electroconvulsive Therapy (ECT)• Transcranial Magnetic Stimulation (TMS)• Or any service determined as an outlier.
The benefit may allow you to choose services through either an IBH network provider or a non-‐network provider. Non-‐network providers must be independently licensed and still must follow plan requirements of submitting documentation of evidentiary standards and medically necessary care. Call IBH to determine if a non-‐network provider is eligible for coverage under your plan.
While there are no treatment visit or hospital day limits in the benefit plan, all claims for treatment (including those delivered before any pre-‐authorization) are subject to review for medical necessity and appropriateness of care by IBH.
All claims are subject to benefit eligibility as well as plan exclusions and limitations at time of service.
Services Not Included in the Managed Behavioral Health Plan in PPO Plus or Keystone HMO:
1. Services performed by the patient onhim/herself or performed by immediatefamily, or an individual residing in the samehousehold, including but not limited to aspouse, child, brother, sister, parent, or thespouse’s parent, even if that individual is aqualified provider.2. Services provided by someone notlicensed by the state to treat the conditionfor which the claim is made and toindependently bill fee for service and/or nottrained or experienced to treat a specificcondition under review.3. Extended hospital, residential or programrelated stays that are unrelated tomedically necessary and approvedtreatment.4. Services furnished by or for the U.S.government, Federal and state fundedagency or foreign government, unlesspayment is legally required.5. Treatment that is of an experimental oreducational nature. Procedures which areexperimental, investigational, or unproven.
Therapies and technologies whose long-‐term efficacy or effect is undetermined, or whose efficacy is no greater than that of traditionally accepted standard treatment. 6. Services applied under any governmentor publicly funded program or law underwhich the individual is covered.7. Services for which a third-‐party is liable.8. New procedures, services, andmedication until they are reviewed forsafety and efficacy, through acceptedevidentiary review.9. Services that are primarily to assess oraddress neurodevelopmental disorders areto be considered as medical conditions andas such not covered under the mentalhealth benefits. With the exception ofAttention Deficit/ Hyperactivity disorder,and Tic disorders which are covered by themental health portion of the plan.10. Custodial care or supportive counseling,including care for conditions not typicallyresolved by treatment.11. Alternative treatment methods that donot meet national standards for behavioral
health practice, including but not limited to: regressive therapy, aversion therapy, neurofeedback or neuro-‐biofeedback, hypnotherapy, acupuncture, acupressure, aromatherapy, massage therapy, reiki, thought-‐field energy, art or dance therapy. 12. Services not medically necessary. Allservices must be medically necessary. Thefact that a physician or other provider mayprescribe, order, recommended, or approvea service or supply does not, in itself, makeit medically necessary, even though it is notspecifically listed as an exclusion orlimitation.13. Court-‐ordered treatment. If a participant is currently in a course of treatment that is confirmed as being required by a court, the treatment may be considered only as long as it is medically necessary. 14. Psychological or neuropsychologicaltesting, unless specifically pre-‐certified byIBH.15. Inpatient treatment for co-‐dependency,gambling and sexual addiction.16. Treatment primarily for chronic painmanagement or neuropsychologicalrehabilitation.17. Treatment primarily for theconvenience of the patient or provider.18. Treatment provided primarily formedical or other research.19. Charges for services, supplies ortreatments which are primarily educationalin nature; charges for services foreducational or vocational testing or trainingand work hardening programs regardless ofdiagnosis or symptoms; charges for self-‐help training or other forms of non-‐medicalself-‐care.20. Charges primarily for marriage, career,or legal counseling, mediation, or custodyrelated services.
21. Treatment of sexual dysfunction notrelated to organic disease. Sex therapy.22. Services provided if covered individualwould not legally have to pay for them ifthe covered individual were not covered bythe Plan or any other medical plan, to theextent that exclusion of charges for suchservices is not prohibited bylaw or regulation.23. Evaluation or services not required forhealth reasons, including but not limited toemployment, insurance orgovernment licenses, and court ordered,forensic, or custodial evaluations.24. Charges for obtaining medical recordsor completing a treatment report, and latepayment charges.25. Methadone maintenance.26. Speech and language evaluations orspeech therapy.27. Charges for failure to keep ascheduled visit, charges for completionof a claim form.28. Therapy or treatment intendedprimarily to improve or maintain generalphysical condition or for the purpose ofenhancing job, school, athletic orrecreational performance.30. Expenses for pastoral counseling,marriage therapy, music or arttherapy, assertiveness training, social skillstraining, recreational therapy, stressmanagement, or other supportive therapies.31. Long-term treatment at a
residential treatment facility, or long term rehabilitation therapy.32. Smoking cessation programs notcovered under the medical plan.33. Therapeutic foster care, grouphome, halfway or three-quarter houses,residential/therapeutic schools, camps.34. Any treatment or condition excludedby the medical Plan.
How Managed Behavioral Health Plan Claims Are Paid: Network services require no claim forms. IBH will pay your provider directly. You are responsible for paying coinsurance, copay, or deductible that may apply.
If you use a non-network provider, either you or the provider must submit a claim form and you are responsible for paying the balance of the provider’s outpatient or inpatient mental health or substance abuse charges, after the IBH payment of the non-network benefit based on the IBH allowable rate. The IBH allowable rate is the rate for the IBH fee schedule for specific network services. Remember if you use non-network providers, your financial responsibility, the amount you pay, for non-network mental health or substance abuse care is higher and is based on the IBH allowable rate. Claims may be mailed to:
Integrated Behavioral Health Claims Department P.O. 30018 Laguna Niguel, CA 92607-‐0018
How to File a Managed Behavioral Health Plan Appeal: For purposes of the appeal procedure, a mental health or substance abuse claim appeal includes any request for benefits or authorization that is denied either in part or in whole. You or your provider may appeal a claim or other adverse benefit decision directly to IBH. The appeal must be submitted to:
Integrated Behavioral Health Quality Management—Appeals P.O. Box 30018 Laguna Niguel, CA 92607-‐0018
Appeals Process: Policy: Integrated Behavioral Health shall offer an appeals process for both members and
providers. Such policy shall include reasonable efforts to resolve concerns and disagreements prior to a formal appeal process through collegial and non-‐adversarial means. The appeals process is consistent with ERISA guidelines.
Procedures: IBH provides an appeal process for members, providers and employers/health plans hereinafter referred to as claimant. This appeal process is available for any adverse benefit decision and/or when disagreements occur regarding decisions or potential decisions about authorizations for proposed treatment, claims payments, or treatment reviews. When such adverse benefit decisions or disagreements occur, the member, provider or employer/health plan may request reconsideration by phone or mail. A Senior Care Manager or supervisor
responds to this Request for Reconsideration immediately. The response is communicated by phone and mail. Facsimile is used when issues are urgent.
Should this reconsideration process fail to satisfy the issue, the claimant may submit a formal appeal for review. This Level 1 Appeal may be a written request or telephonic. It is responded to within the timeframes outlined below for the particular type of claim. A clinical person, with appropriate expertise, and other than the care manager who effected the denial must conduct the appeal review. Such clinician may not be supervised by the initial reviewer. The response is communicated by phone and mail. Facsimile is used when issues are urgent.
External Review Option: If the appealing party continues to be dissatisfied, a second level appeal can be requested in writing or telephonically and is conducted by an external clinical person with appropriate expertise. This decision is also provided within the timeframes outlined below for the particular type of claim. The providers and members are informed by mail or facsimile, depending on the urgency.
All protected health information shall be managed within HIPAA regulations and within other federal law and regulations specific to confidentiality of behavioral health medical data.
Timeframes: Expedited/Urgent Care Claims Initial Claim Response Timeframe: 48 Hours Request Missing Info from Claimant: 24 Hours Claimant to Provide Missing Info: 48 Hours Claimant to Request Appeal: 180 days Appeal Response Timeframe: 72 Hours
Pre-‐Service Health Care Claims Initial Claim Response Timeframe: 15 Days Extension (Proper Notice/Delay Beyond Plan Control): 15 Days Request Missing Info from Claimant: 5 Days Claimant to Provide Missing Info: 50 Days Claimant to Request Appeal: 180 Days Appeal Response Timeframe: 30 Days
Post-‐Service Health Care Claim Initial Claim Response Timeframe: 30 Days Extension (Proper Notice/Delay Beyond Plan Control): 15 Days Request Missing Info from Claimant: 30 Days Claimant to Provide Missing Info: 50 Days Claimant to Request Appeal: 180 Days
Appeal Response Timeframe: 60 Days
Additional Claimant Rights: The claimant is entitled to receive, free of charge, and have access to all relevant documents and information relied upon in making the claim determination.
Once you have completed all mandatory appeals, you and your plan may have other voluntary alternative dispute resolution options. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.
Under ERISA Section 502(a)(I)(B), you have the right to bring a civil action. This right can be exercised when all required reviews of your claims, including the appeal process, have been completed, your claim was not approved, in whole or in part, and you disagree with the outcome.
The above-‐described Appeal Process is subject to all applicable State and Federal laws and regulations.
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